QUESTION: I have recently begun treating veterans under the VA Choice program. I am getting paid just fine for CMT services and evaluation and management services, but have been denied all physical medicine codes including both massage 97124 and manual therapy 97140. I have included modifier 59, but the denial from the VA states I am missing a modifier. I called, but they would not tell me what modifier is needed. Can you help?
Indeed, the Veterans Administration is paying directly to chiropractors for care under the VA Choice or PC3 Program. There are currently two administrators for this program: Health Net for the northeast and TriWest for the southwest (approximate geographic regions). Treatment, as you have realized, must be authorized, but does indeed pay for exams, manipulation, therapies and X-rays.
The authorization for chiropractic care is typically 12 visits and includes exam, CMT and physical medicine services – specifically massage and manual therapy, as you noted. There can be additional physical medicine services authorized upon request and visits can be approved beyond 12. I have seen authorizations for as many as 72 visits for a five-month period. (This is not a typo: 72 within five months. Clearly a severe and chronic patient.)
Once you have been authorized, billing is sent to the carrier on a standard 1500 claim form. CMT coding does not need any modifier; however, evaluation and management (E&M) coding, whether new or established patient codes, must also be appended with modifier 25 when treatment and E&M are provided on the same date. This is not unusual and how all claims with treatment and E&M are coded for chiropractic claims.
The same applies to massage 97124 or manual therapy 97140, wherein you are required to append these codes with modifier 59 or XS to identify that the services are distinct and independent of the CMT performed.
The Missing Modifier
Of course, you have apparently done all of the above and note the claim was still not paid due to a missing modifier. That missing modifier needed for physical medicine services is modifier GP. The GP modifier is used to indicate the services were delivered under an outpatient therapy plan of care. Essentially all federal claims use this, including the VA. Without this modifier, the physical medicine services will be denied.
Therefore, when billing a VA claim under VA Choice, include modifier GP for all PT codes in addition to any other modifier(s) required. The order of the modifiers is not important; simply ensure all modifiers appear. For instance, you can code 97140 GP 59 or 97140 59 GP.
Not Just for VA Billing
This GP modifier is also required for Medicare claims when a chiropractic provider is billing for a physical medicine service and needing a denial for a secondary payment. This means for Medicare claims, you will now have two and possibly up to three modifiers needed for a proper denial.
For instance, for massage or manual therapy, you need a GY (excluded service) GP (outpatient therapy) and 59 (separate and distinct) when billed with CMT 97140 GY GP 59. This GP requirement for Medicare began this year; without this modifier, Medicare will not provide a proper denial for the secondary payer.
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.
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