Skip to main content

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.


You Might Also Like...

News

Portal for Reporting How Relief Money Was Spent Opens Jan. 15 — With a Change

Oct 5, 2020

The HHS portal will be open for 30 days, and providers have to adopt a new way of calculating revenues lost due to the pandemic.

News

New CPT Code Available to PTs Could Help Offset Coronavirus-Related Expenses

Sep 25, 2020

The new code is aimed at additional supplies and staff time devoted to stopping spread of the virus.

News

HHS Releases Details on Provider Relief Fund Reporting

Sep 23, 2020

If you received $10,000 or more in CARES Act relief funds from HHS, you are required to report on how you spent the money.