Physical Therapy Medicaid Plans and 97140 and 97530 Denied


Local Chapter Officer
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Hello Coders!

From all my Medicaid plans are all denying 97530 with 97140. However, I do have the modifier 59 attached to the 97530. They say it is denied because of NCCI edits. I reviewed the NCCI, but it does not look like they changed the rule. Has anyone else come across this problem? I get told just appeal, but it will be denied anyway. It is a maddening situation.



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Some plans are going to require that you submit medical records to substantiate that you can unbundle these codes regardless of using the 59 mod. I run into this denial literally on every single Humana claim that 97530 & 97140 are billed together on and always have to send recs. We started to drop our Humana claims to paper and attach the records and some will be paid however they still often require follow up to ask the plan to make sure they are reviewing the records along with the claim but it was easier than having to appeal them after the fact and send a letter and records. We don't run into this CCI as frequently with Medicaid plans in particular except for one (Indian Health Services-i'm in AZ) so we started to drop those to paper as well and attach records and that eliminated the problem. It will just depend on the plan and how they handle CCI, in general this is the biggest CCI denial we run into but most of the plans pay with the use of the 59 modifier alone. I can tell you that I rarely get denied after sending the records, generally our therapists are using the code appropriately and are documenting to allow unbundling. Hope this helps!

Missy Lupercio CPC-A

Spooner Physical Therapy
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