In the September issue of Chiropractic Products, I went over some frequently used modifiers that can cause denials and delays in chiropractic billing.¹ That article covered evaluation/management modifiers, professional/ technical modifiers, greater than/reduced service modifiers, and Medicare modifiers.

This article will cover the two most commonly used, and most often misunderstood, modifiers. Both of these modifiers are typically used when billing physical medicine codes.

Multiple Procedures
–51: When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier -51. Or you can use the five-digit code 09951.

As of January 2006, the AMA CPT code book advises to never use modifier –51 with therapy codes 97001 to 97755. This would include any of the frequently used physical therapy services such as hot packs, muscle stim, ultrasound, therapeutic exercises, or activity codes.

The biggest news to chiropractors is that this new rule regarding the use of the  –51 modifier goes against everything chiropractors have been taught since the invention of the chiropractic manipulative treatment (CMT) codes. Until recently, chiropractors were told that they must always use the –51 modifier whenever they billed for an extremity adjustment (98943) on the same visit as a spinal adjustment (98940–42). This is no longer the case. The modifier –51 is not needed after the extremity CMT code 98943. This means that the total value (charge) of the extremity adjustment is also considered. Previously, using the –51 modifier after the extremity adjustment allowed the carrier to “discount” the second (multiple) procedure by 50%.

The multiple procedure modifier –51 is also never used after a designated “add-on” code, such as prolonged physician service codes, which are specifically designed to be billed with a primary service code and are not considered multiple procedures.

There is a whole page of CPT codes listed as “exempt” for the use of the –51 modifier in the back of the AMA CPT code book under appendix E.

Distinct or Independent
–59: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier –59 is used to identify procedures or services that are not normally reported together but are appropriate under the circumstances. “...not ordinarily encountered or performed on the same day by the same physician.”

The –59 modifier may represent a different session or patient encounter, a different procedure, or a separate injury. However, when another, more descriptive modifier is appropriate, it should be used rather than the –59.

What most offices do not realize is that the –59 modifier normally flags the claim for further scrutiny. Although it is necessary to use in certain circumstances, this use of the –59 modifier is like putting a large target on your claim. Similar to using a non-specific code like an unlisted code, the –59 modifier “catches” within the insurance carrier’s software as an unusual claim and requires hand overrides for the claim to get paid.

However, some physical medicine and rehabilitation services require the –59 modifier due to their time and/or descriptors to allow payment for the same or similar services. Correct Coding Initiative (CCI) edits pair a “timed” CPT code with another “timed” CPT code or a non-timed CPT code. These edits may be bypassed with modifier –59 if the two procedures of a code are performed in different timed intervals. CCI does not include all edits pairing two physical medicine and rehabilitation services (excepting “supervised modality” services) even though they should never be reported for the same 15-minute time period.

For example CPT code 97140 (manual therapy techniques, one or more regions, each 15 minutes) and CPT code 97530 (therapeutic activities, direct patient contact, each 15 minutes) is often bypassed by using modifier –59. However, you can use the modifier –59 only if these two procedures are performed in distinctly different 15-minute intervals. The two codes cannot be reported together if performed during the same 15-minute time interval.

CMT and Manual Therapy
A –59 modifier may also be used to separate such services as manipulation (98940–43 codes) and manual therapy (97140), if these services were performed on different anatomical regions and properly linked to separate diagnosis codes.

If a patient has two separate “regions” diagnosed (neck and shoulder), and an adjustment was done on the neck (98940) and mobilization was done on the shoulder (97140), a modifier of –59 would be appropriate after the 97140 code to show distinct different services.

Most carriers will not pay for a 989 code and 97140 if both services are performed in the same anatomical region; (the spine is considered one region, five areas). A separate anatomical region must be diagnosed to link to the 97140 code. If the 97140 code is being billed as “myofascial release” with an adjustment code, a 98940 and a 97140–59 may be appropriate as long as the 97140–59 code is linked to a muscle diagnosis and the 98940 code is linked to a structural/joint diagnosis.

Other CMT and CCI Edits
Although CCI edits were designed to detect codes billed to Medicare and Medicare carriers, many third-party payors use the edits as a cost-containment protocol. Whether these edits are legitimate for reducing payments by carriers is certainly debatable and should be questioned. And, while CPT coding policies may not prohibit billing services in combination with one another, the CCI edits program does, in many cases, inappropriately bundle services. Knowing how the edits are determining your payments is important in understanding how to fight inappropriate denials.

For example, the –59 modifier may help separate services such as a massage (97124) or neuromuscular re-education (97112) from a CMT code. The key to properly billing and modifying these services is also linking the procedure to the appropriate diagnosis and anatomical regions.

Physical therapy services described by CPT codes 97112, 97124, and 97140 may not be separately reportable when performed in a spinal region undergoing CMT. If these physical therapy services are performed in a different anatomical region, the provider is eligible to report these physical therapy codes using the –59 modifier. Medical necessity is always the key.

Testing and E/M
The modifier –59 may also be appropriate to use if special testing is done “above and beyond” what would normally be considered to be included with evaluation and management service.

Orthopedic, neurological, and neuromuscular procedures such as muscle testing, checkout for orthotic, physical performance tests, and some kinesiology testing may be billed on the same day as an evaluation with the appropriate documentation and coding. A –59 would be used after the additional testing code, and a –25 would be used after the E/M service. If an FCE (Functional Capacity Exam) is performed, it already includes an evaluation and would not be appropriate to be billed with a –59 modifier and an additional E/M service on the same day.

It is important to note that adding any modifier to a CPT code alters the standard work value of a given CPT code. This is especially true with the –51 and –59 modifiers.

Finally, remember that choosing the proper CPT code and its modifier is essential for payment; however, it is not just which codes get billed, but what the documentation says, that counts. Improper use of codes or modifiers may result in a fraudulent claim.

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. Contact her at naca_csoyring@yahoo.com.

Reference
1. Soyring C. Modifiers: Knowledge is Power. Chiropractic Products. 2006; 21(9):48–49.