Wiki APPROPRIATE MODIFIERS FOR PHYSICAL THERAPY

[cswaggard]

Hey, so I'm having a problem with Humana denying physical therapy charges for modifier 59 not being an appropriate modifier. I am trying to bill therapy codes 97110, 97150, 97140, 97112 and 97012. According to NCCI edit if 97150 & 97110 are billed together only 97150 will be paid, if both 97150 & 97140 are submitted only 97150 will be paid and if both 97012 & 97140 are submitted only 97012 will be paid. I have always added the 59 modifier to the code that will not automatically be paid in the pass and charges were paid, but now they are denying for the following: THIS CLAIM CONTAINS CODE PAIRS FOUND TO BE UNBUNDLED ACCORDING TO CMS AND NCCI. THIS SERVICE WAS INCLUDED UNDER A MORE APPROPRIATE PROCEDURE CODE ON THE SAME DATE OF SERVICE. NCCI states that 59 modifier is for Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. In this case services were on the same day but patient had group therapy and did manual therapy. I'm trying to see what modifier is needed, Can I get some assistance? Thanks

 

[TThivierge]

Hi There CSwaggard
Modifiers for physicals therapy are LT, RT per limbs and GO GN GP, 95 and 97 check in HPCPS and CPT manual. These are used per type of Phys Therapy obtain. Also put referring licensed provider order it and amount of same type of visits in the month. Also if got 2 session earlier on same body part area helped put both previous dates on current claim. Check with your payer and get pre- authorized too.
I hope helped you some what
Lady T

 

[melissadrey]

Hey, so I'm having a problem with Humana denying physical therapy charges for modifier 59 not being an appropriate modifier. I am trying to bill therapy codes 97110, 97150, 97140, 97112 and 97012. According to NCCI edit if 97150 & 97110 are billed together only 97150 will be paid, if both 97150 & 97140 are submitted only 97150 will be paid and if both 97012 & 97140 are submitted only 97012 will be paid. I have always added the 59 modifier to the code that will not automatically be paid in the pass and charges were paid, but now they are denying for the following: THIS CLAIM CONTAINS CODE PAIRS FOUND TO BE UNBUNDLED ACCORDING TO CMS AND NCCI. THIS SERVICE WAS INCLUDED UNDER A MORE APPROPRIATE PROCEDURE CODE ON THE SAME DATE OF SERVICE. NCCI states that 59 modifier is for Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. In this case services were on the same day but patient had group therapy and did manual therapy. I'm trying to see what modifier is needed, Can I get some assistance? Thanks

Hello, I work in the Therapy world as well and just wanted to add some bit of info to share with you with regards to Humana. Humana requires modifier 96 on most lines except when billing code's 97140 & 97116. Also when providing PT services on our claims we only use modifier 59 on code 97535. Humana only wants 1 diagnosis per claim preferably an F code if applicable. There are CCI Edits in regards to billing certain codes together and you have mentioned a few above. Rules have already been placed and it is up to us certified coder's & billers to know them and follow them. There are CCI edits in place which means that we can't unbundle certain codes by adding a modifier on them and expect payment. That can lead to audits and hefty fines. I hope some of this information helps in your seek to find answers. Happy Holidays!