Commonly Misused Modifiers

In the English language, modifiers describe information such as the who, what, how, why, or where of a situation. In coding, modifiers also describe information. Using a modifier correctly will clarify a situation or service. Often in chiropractic, confusion as to the proper use of modifiers may result in denials and unnecessary time correcting claims that were unjustly denied.

CPT or HCPCS Level II code modifiers may be two letters, two numbers or a combination of the two. Modifiers indicate that a specific circumstance has altered a service or procedure. Although the event has changed, a modifier will not change the definition or the code. Quite frankly, a modifier will aid in communicating the specifics of a particular encounter. This communication will alleviate any question of fraud or abuse by the carrier.

Modifiers can be classified as having different purposes. Some are considered payment modifiers, which directly impact how much you are allowed to collect for the service. Other modifiers are considered informational. They may show why two services, usually bundled together, should be regarded as separately billable.

Examples of information modifiers include the 25 modifier, which explains why an evaluation and management service (examination) has been unbundled from the chiropractic manipulation. Another is the 59 modifier, which describes why the "distinct procedural service" has been unbundled from other services such as therapy and chiropractic manipulation.

There are many modifiers used for various carriers, including Medicare. Let's discuss proper use of some of the most common modifiers for commercial carriers in chiropractic.

Modifier 25

Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day or procedure.

Modifier 25 has been ranked by some as one of the most commonly rejected modifiers. In chiropractic, this modifier has become especially troublesome when seeking reimbursement from certain carriers.

Chiropractic manipulation consists of three components: the pre-assessment, the actual manipulation and the post-assessment.  Since the services 98940-98943 are expected to consist of a minimal examination, it is often inappropriate to unbundle the manipulation's evaluation and management (E/M) service. Anytime the 25 modifier is appended to the E/M codes (99202-99215), the chart notes must indicate that the procedure was separately identifiable.

I do not recommend adding modifier 25 if the E/M would be considered minimal or done to establish the presence of a segmental and somatic dysfunction (subluxation). The documentation must satisfy specific criteria for the E/M service to be reported. The medical necessity and rationale of the service should be documented.

Was this a new injury or an exacerbation? Did the symptoms change or significantly worsen? The diagnosis does not have to change necessarily, but did you change the treatment plan or treatment goals due to the examination procedure?

Your documentation is always necessary to establish the separately identifiable examination rationale. If it was not written, it never happened. The phrase "The patient's condition required..." helps explain the circumstances. By explaining the change in circumstances, what prompted you to perform the service can be understood.

When describing what you did, I recommend stating, "The patient's condition required a significant, separately identifiable E/M service above and beyond the usual manipulation services." This statement will leave no doubt in the carrier's mind that you felt justified in unbundling the manipulation and examination.

A self-test to establish if you are justified in using modifier 25 is to ask yourself if you documented the extra work performed, the medical necessity of the work, and what the extra work was compared to the usual work performed in the manipulation service.

Modifier 59

Distinct procedural service.

Modifier 59 is also often misused. A typical example of this modifier is when therapeutic services such as massage (97124) or soft-tissue mobilization / trigger-point therapy (97140) is used. Using this modifier signifies that a procedure or service is independent of other codes reported and deserves separate payment.

The code selection must be genuinely distinct and separately reportable from other codes. It must also meet the minimum threshold of the performance of the procedures for a minimum of eight minutes.

The definition of modifier 59 advises that you should not use it when a more descriptive modifier is available. In some instances and with certain carriers, it may be advantageous to use the X subset modifiers instead of the 59 modifier. The X subset of modifiers may be useful when performing distinct procedural services on separate sites on the body.

In 2014, the Centers for Medicare and Medicaid Services created the X (EPSU) modifiers. The more specific X modifiers may yield information for the carrier in a way modifier 59 does not. All carriers do not use the X subset modifiers, so check with individual payers to see which modifiers they prefer for a distinct procedural service.

X subset modifiers may be appropriate for a code when documentation shows at least one of the following:

• XE Separate encounter; a service that is distinct because it occurred during a separate encounter
• XP Separate practitioner; a service that is distinct because a different practitioner performed it
• XS Separate structure; a service that is distinct because it was performed on a separate organ / structure
• XU Unusual non-overlapping service; use of a service that is distinct because it does not overlap usual components of the main service

If you are considering using the XP modifier (separate practitioner), a service that is distinct because a different practitioner performed it, remember that certain carriers and Medicare follow this rule found in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.5: "Physicians in the same group practice in the same specialty must bill and be paid as though they were a single physician."

Modifier 96 and Modifier 97

Habilitative and rehabilitative services.

In February 2022, Humana updated its billing policy for habilitative and rehabilitative services to include 96 and 97 modifiers. Since a chiropractor most often will administer rehabilitative services, modifier 97 will be used for Humana Commercial plans. Modifiers 96 and 97 should not be used together on the same claim.

Rehabilitative services help an individual keep, get back or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt or disabled.

One such code that affects chiropractic claims is skilled therapeutic exercise procedures (97110), considered rehabilitative.

RT and LT Modifiers

Right side and left side.

RT and LT are location modifiers used to identify where a procedure was performed. For example, when ordering functional orthotics, it is recommended to use the HCPCS code L3020. L3020 is used for foot inserts, molded to patient model, longitudinal / metatarsal support. The code is used for each foot. Since you are using this procedure for the right and left feet, you would use L3020 RT for the right side and L3020 LT for the left side.

These are just a few of the modifiers that come into play in our day-to-day claims in the chiropractic office. Knowing the rules of modifier use is complex, but necessary, because they must be addressed frequently when submitting claims. Using the modifiers correctly will make sure you get paid for the services you perform.