Can You Overuse a Modifier? Guidelines for Using 59 vs. XS

Question: I recently received a letter from Anthem indicating I was overutilizing modifier 59, stating my use was at a higher ratio than expected. It also appeared to indicate I may or should be using modifier XS instead. Can you shed more light on what is going on?

As you are likely aware, there are requirements related to modifier 59 when you are utilizing the codes 97124 (therapeutic massage) and 97140 (manual therapy), or 97112 (neuromuscular re-education). Per the Correct Coding Initiative Edits (CCI Edits), "Physical medicine and rehabilitation services described by CPT codes 97112, 97124, and 97140 are not separately reportable when performed in a spinal region undergoing chiropractic manipulative treatment (CMT).

"When these physical medicine and rehabilitation services are performed in a different region than CMT, and the provider is eligible to report physical medicine and rehabilitation codes, the provider may report CMT and the above codes using modifier 59 or XS."

You will notice that even in the edits, it does indicate modifier XS, which was also indicated to you via Anthem's correspondence. It is most likely you should be using XS instead of 59 in most instances for massage or manual therapy.

Service Rates and Necessity: Are You Doing Due Diligence?

However, let's first focus on and discuss the utilization of these three services. The letter is implying or alluding that you are utilizing these services with manipulation at a rate higher than average or expected. In my experience in dealing with chiropractic audits, this most commonly relates to massage 97124 or manual therapy 97140, which includes services like myofascial release, soft-tissue mobilization, trigger-point therapy, etc.

Of course, these services may be medically necessary; but keep in mind that standard care plans indicate and anticipate them to be during the acute phase of care and diminish as the patient progresses to more active care protocols. I recommend that you ensure you're not providing these services too long or late in the care plan, as with that timing it may seem more as "spa-style" or often referred to as "feel good" – in the absence of specific therapeutic value that identifies separate goals and purposes at that phase of care.

I would also make sure your documentation indicates clearly that you are providing either of those services to a part of the body that is not being manipulated on the same visit. The use of modifier 59 or XS indicates the service is separate and distinct service from manipulation.

Which Modifier to Use (and When to Use It)

This is why the use of modifier XS would technically be more correct or accurate than 59. The modifier XS delineates a separate structure; or specifically a service that is distinct because it was performed on a separate organ/structure.

This XS modifier is a subset modifier of 59 that allows for greater distinction than 59 describes; as such, it would be the best modifier to use when doing 97124 or 97140 with spinal CMT, as to be separately reportable it must be to a separate region from the CMT.

You should certainly provide and do services as you find medically necessary, but be mindful of and ensure your documentation can support and identify the necessity of those services with clear goals and results of care.

That said, the overuse of 59 may not only be related to massage or manual therapy in some offices. I have noted that some providers are getting these same letters and are not billing massage or manual therapy at all. However, they are still using modifier 59 frequently, and in most instances improperly on codes for which is it not necessary. Some providers have mistakenly identified or assumed that the modifier 59 is necessary on all or at least some of the other physical medicine codes beyond manual therapy and massage, which is incorrect.

There is no need for the modifier 59 with standard physical medicine and rehabilitation codes during a chiropractic treatment plan: services such as therapeutic exercise 97110, therapeutic activities 97530, mechanical traction 97012, or other common physical medicine and rehabilitation services.

None of those services has any requirement on a chiropractic claim to distinguish the service as separate and distinct from CMT – meaning there is no requirement for the use of 59 or XS. Many plans will not deny because you utilize a modifier that is not necessary, but because its use impacts your claim ratios for use of the modifier, resulting in a higher-than-expected rate. Again, make sure you are only using 59 / XS for massage and manual therapy; and only on the same visit as a CMT service.

Not all Insurers Are the Same

A final note: While your question was based on how Anthem is handling your claims, not every insurer is the same, of course. UnitedHealthcare claims require you to use modifier GP for all physical medicine codes. Therefore, for claims to that payer, you would need to indicate modifier 59 or XS along with GP. The order of modifiers does not matter (GP XS vs. XS GP). What is important is that they both appear on the claim line. This GP modifier also applies to claims you send to the VA or Medicare; but not 59 or XS unless the service being billed is 97124 or 97140.

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