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  • PTs Not Yet Affected by Changes to 59 Modifier Coding in Medicare

    Additional requirements around an important Medicare coding modifier are being instituted by the US Centers for Medicare and Medicaid Services (CMS), but the changes do not affect physical therapists (PTs)—at least not yet.

    The bottom line? For now, PTs can continue to use the 59 modifier under the Correct Coding Initiative.

    The changes announced by CMS in August 2014 apply to the 59 modifier in payment claims—that's the code under the health care common procedural code system (HCPCS) used to represent a service that is separate and distinct from another service it's paired with. In an effort to tease out precisely why the service is distinct, CMS is requiring some providers to use different modifiers instead of the 59 modifier. The new modifiers —XE, XP, XS, and XU—are intended to bypass a CCI edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service.

    "We're receiving questions from members about whether they have to use some new modifiers issued by CMS, and the answer at this time is no,” said Gayle Lee, JD, APTA senior director of health finance and quality. “As of February, 2015, PTs are being instructed that these new modifiers are not required for physical therapist services. However, at some point in the future, PTs may need to use these new modifiers instead of the 59 modifier, so it's important that they stay abreast with this change as implementation continues."

    In a recently issued Medicare Learning Network guidance document (.pdf), CMS stated that "providers may continue to use the 59 modifier after January 1, 2015, in any instance in which it was correctly used prior to January 1, 2015." The agency writes that "additional guidance and education as to the appropriate use of the new … modifiers will be forthcoming as CMS continues to introduce the modifiers in a gradual and controlled fashion."

    APTA will continue to monitor this issue and share news of any changes.


    • When should our out patient PT clinic start using these modifiers? These are used instead of the 59 or with it?

      Posted by LANA on 2/11/2015 2:21 PM

    • any updates on if we should be using the new modifiers in outpatient hospital PT setting?

      Posted by Susan Steady -> AGX[ on 8/11/2015 11:50 AM

    • We are looking for more information and examples of the new modifiers with PT CPT codes. Please advise.

      Posted by JENN on 9/2/2015 12:30 PM

    • Since this article is from February please clarify if using the 59 modifier is still appropriate or if we should transition to the "x" modifiers?

      Posted by Andrea on 12/3/2015 9:59 AM

    • Do you have an update for the use of 59 modifier and the new codes (XE,XS, SP and XU)? Thank You

      Posted by Michael DuBois on 3/11/2016 10:42 AM

    • BCBS of Nebraska is now denying all claims with modifier -59. They are requesting use of of the new modifiers. However, none seem to be suited when billing 97530, 97140, and 97110 together. I'm leaning towards applying XU to 97530... any suggestions?

      Posted by Nicholas Muchowicz -> @JW^<F on 6/8/2016 10:41 PM

    • Will you be educating how to pick correct one ? XU,XEm XS,XP ??? ANy time soon

      Posted by Samantha Martel -> @JS_BG on 9/1/2016 11:54 AM

    • I am posing a question on the I-10 side, when or what is appropriate code to use for PT visit? z51.89 is an aftercare...

      Posted by Marenie Begay on 5/10/2017 9:16 AM

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