Why the Automatic Denials for Modifiers 25 and 59?

QUESTION: Recently, I have been getting a rash of denials for Blue Cross Blue Shield and UnitedHealthCare anytime I use modifier 25 for evaluation and management codes (99201-99215) or modifier 59 for manual therapy 97140 and massage 97124. Are these codes no longer payable by these carriers?

Your experience is one shared by many chiropractic providers who bill through those plans. It appears to be the national trend, but by far is more prominent in Texas and Illinois. Yes, those services are payable and as you indicated, the use of the modifiers is necessary anytime you bill the above services in conjunction with chiropractic manipulative therapy (98940-98943).

The 25 modifier indicates that the evaluation and management service is separate, distinct, and above and beyond the usual pre- and post-service work associated with the manipulation. The 59 modifier distinguishes manual therapy or massage being performed to a separate and distinct region not part of the manipulation to the spine.

Modifying Auditing Policies

However, Blue Cross Blue Shield of Illinois has outlined the following protocol, which appears to be occurring not only in Illinois, but also in several other states and plans. BCBS of Illinois issued a very brief announcement in the Blue Review titled "Code-Auditing Enhancement." In the announcement, BCBS said it was implementing "code-auditing enhancement" in the form of software it asserted would help audit claims by "clinically validating modifiers."

As a result of this update, providers began receiving denials on codes that require the 59 and 25 modifiers, even when providers use the modifier code correctly according to CPT guidelines. The denial indicated the standard response: "The procedure code is inconsistent with the modifier used or a required modifier is missing." This resulted in essentially an automatic denial for codes with these modifiers.

These denials appear promulgated by what the carriers see as overutilization and lack of medical necessity. Clearly, this type of denial is unreasonable, as the carriers are not validating with even a request for notes, but an assumption that care was not provided in the manner required or was not necessary. The use of 59 and 25 are clearly appropriate per the CPT reference and without a request or review to verify that the notes match the purpose of the modifier.

However, with that in mind, you must be sure that the evaluation and management were not routine and not part of the regular day-to-day evaluation associated with treatment; and that there is clear distinction of application of the CMT to a region of the spine not part of the area of massage (97124) or manual therapy (97140).

Appealing an Insurance Denial Involving the 25 / 59 Modifiers

The appeal must be initiated by the provider and most plans will accept an online appeal or claim inquiry. It is very important to file within the time frame for an appeal, as these plans often only allow 180 days from the date of the denial. This, of course, creates a great deal of administrative work and strain for the small office, and there should be engagement by your patient to appeal, who may also go to their employer, union or the department of insurance.

I suggest that with the appeal, you should send a copy of any exam form used, as well as the detailed interim history that documents a level of service above and beyond the day-to-day pre-service evaluation and documentation. If there are other forms used at the time of exam, such as outcome assessments, those should also be included, as they are above and beyond the day-to-day service.

In situations in which the visit was dominated by counseling and the reason for use of the evaluation and management code, the time of counseling must be recorded and represent at least 50 percent of the face-to-face time of the visit. Of course, a summary of the counseling must be present.

For massage and manual therapy, documentation must highlight the specific areas to which the therapy is applied and the type of therapy must be defined (myofascial release, ischemic compression, trigger-point therapy, etc.). These services must then be clearly separate from the region of the chiropractic manipulation.

The five regions are cervical, thoracic, lumbar, sacrum and pelvis (SI joint). If muscle crosses multiple regions, be sure the specificity is clear to the region. If it does cross some regions and not others, be sure the time is divided to demonstrate the time for regions that are different; time can be documented to equal the number of units billed, with time to the same regions not counting. This is more problematic, as often services by style and technique are provided to the same regions. When that is the case, it is inclusive and not separately reimbursable.

State associations have taken up the fight as well and should also be informed so they can use the added data and potentially be a resource to aid in appealing. These denials are systemic and not the fault of the provider (assuming the documentation is sufficient).

The Bottom Line: Don't Compromise Patient Care

I know some providers who provide only an exam on the first visit and treatment on the next when this denial is systemically applied. They also no longer provide manual therapy or massage on the same visit as chiropractic manipulation. This is not a solution I would promote, as it does nothing to prompt the carrier to change and actually validates their denial in some instances.

That said, medical necessity is the driver and certainly, there can be instances in which an adjustment is contraindicated and massage or manual therapy is the best option.

Carriers have acknowledged the issue, but as far as I have seen to date, it has not led to widespread improvement in denials for claims involving the 25 and 59 modifiers. The profession must stand unified to ensure fair treatment and reimbursement for services provided, rather than changing sound treatment protocols to accommodate flawed insurance policies.

Editor's Note: Feel free to submit billing questions to Mr. Collins at sam@hjrossnetwork.com. Your question may be the subject of a future column.