Modifier -59

[Guest guest]

We have had much discussion on the use of Modifier -59 for PT

services within our hospital (outpatient PT services specifically).

We have been told that using the modifier creates a " red flag " with

Medicare. But no one has really been able to explain what impact that

has on us -- will it generate an audit?

In my discussion with private practices in the Denver area, most say

that it is not an issue and have referred me to the Modifer -59

Article (on the CMS website). The article says that the modifier

should only be used to " indicate that a procedure or service was

distinct or indpendent from other services performed on the same

day. " It also goes on to say that it " ... is used to identify

procedures/services taht are not normally reported together, but are

appropriate under the circumstances. "

In our situation, we would use it as an NCCI-associated modifer, and

thus the article goes on to say that, " For the NCCI its primary

purpose is to indictate that two or more procedures are performed at

different anatomical sites or different patient encounter. " However,

in the examples attached to the article, modifer -59 is used for

manual therapy and therapeutic activities -- which we might

frequently use in combination during a treatment session for a post-

op TKR. The example further goes along to say that the " Modifier -59

is: 1) only appropriate if the two procedures are performed in

distictly different 15 minutes intervals. 2) the two codes cannot be

reported together if performed during the same 15 minute time

interval. " Does this seem very different from the NCCI-associated

modifer definition? The definitions given on usage of the modifier

seems somewhat contridictory and it is very confusing to me as to

what is correct.

I am just a Therapist (and proud to be!) and I know that I am making

this harder than it might be but how do your organizations handle the

use of this modifier and has anyone had problems with Medicare when

using it. I want to pass on this information along to our rehab

manager in an effort to meet the needs of our patients and pay the

bills at the same time.

Thanks!

Jim Milani, PT, MA, MPT

Boulder Community Hospital

Community Medical Center

(303)604-4664 (x4654)

[Guest guest]

I am new to the website and I am not sure how to post a reply, but would like

to share what I know about the subject. I am very involved in the local chapter

of the Louisiana Medical Group Management Association in which I sit on the

Board of Directors. We meet once a month and hash out these kinds of things.

Every November Medicare comes and speaks to our group and fills us in as to the

changes for the next year. Each state has a contact person that you can do

directly to. I will be happy to help you in any way I can.

I just recently went to a PT seminar for the changes with our cap.

Attached please find a spreadsheet from the Louisiana Medicare website. This

tells you if a modifier is needed to bill two codes together.

I always use a -59 when I bill 97140 & 97110 together. In 4 years I have never

had Medicare audit anything, ever!

C. Castille

Office Manager

Trey Duhon Physical Therapy

119 Arnould Blvd.

Lafayette, LA 70506

Phone:(337)769-1281

Fax: (337)769-1283

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Modifier -59

We have had much discussion on the use of Modifier -59 for PT

services within our hospital (outpatient PT services specifically).

We have been told that using the modifier creates a " red flag " with

Medicare. But no one has really been able to explain what impact that

has on us -- will it generate an audit?

In my discussion with private practices in the Denver area, most say

that it is not an issue and have referred me to the Modifer -59

Article (on the CMS website). The article says that the modifier

should only be used to " indicate that a procedure or service was

distinct or indpendent from other services performed on the same

day. " It also goes on to say that it " ... is used to identify

procedures/services taht are not normally reported together, but are

appropriate under the circumstances. "

In our situation, we would use it as an NCCI-associated modifer, and

thus the article goes on to say that, " For the NCCI its primary

purpose is to indictate that two or more procedures are performed at

different anatomical sites or different patient encounter. " However,

in the examples attached to the article, modifer -59 is used for

manual therapy and therapeutic activities -- which we might

frequently use in combination during a treatment session for a post-

op TKR. The example further goes along to say that the " Modifier -59

is: 1) only appropriate if the two procedures are performed in

distictly different 15 minutes intervals. 2) the two codes cannot be

reported together if performed during the same 15 minute time

interval. " Does this seem very different from the NCCI-associated

modifer definition? The definitions given on usage of the modifier

seems somewhat contridictory and it is very confusing to me as to

what is correct.

I am just a Therapist (and proud to be!) and I know that I am making

this harder than it might be but how do your organizations handle the

use of this modifier and has anyone had problems with Medicare when

using it. I want to pass on this information along to our rehab

manager in an effort to meet the needs of our patients and pay the

bills at the same time.

Thanks!

Jim Milani, PT, MA, MPT

Boulder Community Hospital

Community Medical Center

(303)604-4664 (x4654)

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