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  • Payers Looking for More Coding Detail

    Physical therapists (PTs), take note: the 59 modifier is a potential red flag for the US Centers for Medicare and Medicaid Services (CMS) and commercial payers.

    The 59 modifier is 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 that in certain cases, providers use different modifiers instead of the 59 modifier. The modifiers—XE, XP, XS, and XU—are intended to bypass a National Correct Coding Initiative edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service.

    When the X modifiers were introduced in 2015, PTs weren't required to use them. But movement toward the use of these modifiers—and greater scrutiny of claims using the 59 modifier—is happening.

    CMS recently issued detailed guidance on the use of the 59 and X modifiers, complete with examples of what it considers appropriate and inappropriate applications. Providers should carefully review the CMS guidance document, as well as check their commercial payer payment policies regarding the use of the 59 modifier versus the X modifiers.

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


    • We are having problems with many commercial insurers denying our claims when 97530 and 97140 are billed together. Even when the 59 modifier is attached to the 97530. I am not sure why this is starting to happen so frequently. They are definitely two different 15 min interventions. Any advice?

      Posted by Heidi Harmon on 2/22/2018 4:17 PM

    • We were getting 97530.59 with 97140 paid and now they are suddenly being rejected. Did something change?

      Posted by LINDA on 5/31/2018 5:06 PM

    • Looking for more information why 97140 billed with 97530 with a 59 modifier is being denied. Have not been able to find any information on this.

      Posted by Sandra on 6/7/2018 10:16 AM

    • Sandra and Linda; the reasons for the denials are difficult to pinpoint without more detail. Please email us at advocacy@apta.org and we can further discuss. Thanks!

      Posted by APTA Staff on 6/8/2018 11:40 AM

    • I am getting denials when using the cpt code 97140 and 97530 together, I use the modifier 59 on the cpt code 97530.

      Posted by gina c on 11/19/2018 4:15 PM

    • @ gina c: Please email advocacy@apta.org with the question and provide information about the payer as well as the denial reason. Thanks!

      Posted by APTA Staff on 11/20/2018 7:52 AM

    • "231 Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present." This was for a treatment that had 2 units of 97140, 1 unit of 97530 and 1 unit of 97012, & the appropriate 59 modifier. Aetna unbundled the claim and reimbursed the 97530 and 97012 and denied the higher paying 97140.

      Posted by Jason Massa on 10/8/2019 3:34 PM

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