Samuel A. Collins
Q: I have had several recent denials for modalities such as hot packs, electric stimulation and infrared heat. Typically, they will pay for one but deny the other(s). Is there a modifier I should be using to ensure they all are paid?
A: There is not a modifier that would necessarily facilitate multiple modalities billed on the same date. Modifier 59 would be the closest one, as it is used to indicate a distinct procedural service with the idea of showing that each modality has its own stand-alone value. But this is not likely. The reason for the denial is that many payers, most recently United Health Care, have increasingly scrutinized the use of multiple modalities on the same visit.
The carrier's assertion for multiple modalities on the same visit is best indicated from the denial. The typical denial will state something of this nature: "You have indicated that you intend to utilize multiple passive modalities per visit. Given the duplicative physiologic effect of many modalities, multiple modalities applied in the same region typically are redundant and have not been shown to accelerate healing or achieve superior outcomes of treatment." This, in short discourse, simply means the carrier does not feel the multiple modalities are necessary and, therefore, they will not be reimbursed.
As upsetting as that may first appear, we must be objective, as the assertion does have some merit. Doctors and billers must be aware of this type of scrutiny and be ready to rebut a denial with solid factors of medical necessity. The general purpose of passive, unattended modalities is to "reduce muscle spasm, reduce pain, increase blood flow, reduce swelling, general sedation, etc." As a consequence, there can be considerable overlap of purpose and goals. This overlap means "duplication," and no carrier wants to pay for two services that provide the same result.
Consequently, providers must be sure that each modality has its own distinct, stand-alone value that is separate from another service. This should be done, first and foremost, on the chart notes, starting with the treatment plan. The treatment plan should outline the specific purpose and goals of each service to ensure no duplication. For example, it most likely may be duplicative and not necessary to apply electrical stimulation and heat to the same region, as the goals and purpose (in the acute phase) are almost identical. Conversely, if the services were done in separate regions, there could be a multitude of reasons for separate application, such as depth of penetration, body contour and/or patient positioning/comfort.
From a billing standpoint, when separate body areas are treated, billers would be able to use diagnosis pointing to indicate the services being done in order to distinctly separate regions and, therefore, avoid duplication. For instance, electrical stimulation may be used in the lumbar spine, but infrared heat would be utilized for the cervical spine to accommodate patient positioning and comfort. To demonstrate this on the CMS 1500 form, a biller would utilize block 24e (the diagnosis pointer) to indicate (i.e., "point") to the specific diagnosis and/or region for each service. In the above example, when electrical stimulation is performed to the lumbar spine only and diagnosis 1 in block 21 is lumbar related, block 24e would contain the number 1 to indicate the service was done to the lumbar spine. Assuming the cervical diagnosis was the second diagnosis in block 21, the line of billing for infrared heat would indicate number 2 in block 24e to designate that infrared heat was applied to the cervical spine.
Certainly, there also could be other issues for multiple uses of modalities, such as one being utilized for superficial purposes and the other for deeper penetration. Billing-wise, there is nothing to indicate this, but an easy rebuttal can be made based on the specific purpose of each, should they be denied.
To be prudent, make sure that if you are doing multiple modalities, take a critical look at why each is provided and be sure that each has a distinct, stand-alone value. If you cannot clearly demonstrate or see the distinction, certainly the carrier will not either.
