Samuel A. Collins
What are the new modifiers that replace modifier 59? Will they allow doctors of chiropractic to be paid for 97140, manual therapy, when done with chiropractic manipulation? Four new modifiers replace and more clearly identify subsets of modifier 59. The effective date for use of the new modifiers was Jan. 1, 2015, with an implementation date of Jan. 5, 2015. Modifier 59 is used to indicate a "distinct procedural service" and these new modifiers further delineate the distinct nature of the service.
- XE Separate Encounter: a service that is distinct because it occurred during a separate encounter.
- XS Separate Structure: a service that is distinct because it was performed on a separate organ / structure.
- XP Separate Practitioner: a service that is distinct because it was performed by a different practitioner.
- XU Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual components of the main service.
Currently, the 59 modifier is used to indicate a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Because it can be so broadly applied, some providers incorrectly consider it to be the modifier to use to bypass the National Correct Coding Initiative (NCCI). It is the most widely used modifier. It is also associated with considerable abuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases.
Modifier 59 has been prominent in chiropractic since the update of CPT code 97250, myofascial release, to 97140, manual therapy, in 1999. As I am sure you are aware, manual therapy 97140 must be performed to a region not being manipulated on the same visit in order to be reimbursed separately from chiropractic manipulation. Regardless of the type of manual therapy, when done in the same region as chiropractic manipulation, the services are considered bundled into the manipulation service.
Often, however, providers will bill 97140 with modifier 59 when the services were not performed on separate anatomic regions, allowing improper reimbursement for the 97140 service. Aetna indicated improper use of 59 following its investigative audits, during which it found that 90 percent of the time modifier 59 was used, manual therapy was performed in the same region as the CMT. Aetna also found extremely poor or complete lack of documentation, with no specificity indicated to establish protocol for separate reimbursement. As a consequence, the insurer began to not pay for 97140 with chiropractic manipulation, regardless of the modifier use.
However, Aetna did relent to some extent and began to pay chiropractors for 97140 services when additional documentation was supplied to not only include use of modifier 59, but also medical necessity and separate regions established in the medical record. Of course, this required considerably more work by the provider by requiring additional clinical information on the service.
For instance, under certain circumstances, it may be appropriate to report CMT codes in addition to 97140. For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code 97140 to the neck region, and CMT to the lumbar region. As separate body regions are addressed, it would be appropriate, in this instance, to report both codes: 97140 and 98940. In this example, the modifier XS would be appended to indicate that a distinct procedural service was provided to a separate anatomical site.
CMS will continue to recognize the -59 modifier, but doctors of chiropractic should note that per CPT instructions, it should not be used when a more descriptive modifier is available. Continued use of modifier 59 will likely result in greater audits, denials and requests for information for payment; therefore, it is better to use the more detailed X (E, P, S or U) modifier when appropriate. This is particularly helpful considering the reimbursement policies of Aetna and United Health Care (Optum Health), both of which specifically audit and request details for use of the 59 modifier when used for chiropractic manipulation with manual therapy.
Feel free to submit billing questions to Mr. Collins at sam@hjrossnetwork.com. Your question may be the subject of a future column.
