Appropriate Use of Modifiers 25 and 59

Hello everyone, and welcome to our podcast series. My name is Natalie Tornese and I am the Senior Solutions Manager at Outsource Strategies International. I wanted to take this opportunity to talk to you about the appropriate use of modifiers 25 and 59, specifically in chiropractic medical billing.

According to recent reports, chiropractic practices saw denials from Blue Cross and Blue Shield (BCBS) for claims billed with modifiers. Most of the claims denied were those that required the 25 or 59 modifier. The Explanation of Benefits (EOBs) indicated that the modifiers were used inappropriately or utilization of the modifier was higher than average.

So what can you do in cases where your claim is denied for this reason? Well, you can appeal the specific denial by demonstrating the valid use of the modifier, or appeal the denial by pointing to the specific documentation that clearly demonstrates medical necessity.

Chiropractic modifiers are reported along with CPT codes to tell the insurance company that that there is something unique about the services being billed. The correct use of modifiers can increase reimbursement. If codes that require a modifier are billed without one, the carrier will reject the claim with an explanation on the EOB of bundling with another service. The key to using modifiers to ensure maximum reimbursement is to understand each payer’s specific recommendations on the matter.

The American Medical Association describes chiropractic manipulative treatment (CMT) (98940-98943) as a form of manual treatment to influence joint and neurophysiological function. The five spinal regions referred to for chiropractic manipulative treatment are the cervical region, thoracic region, lumbar region, sacral region, and pelvic region. The five extraspinal regions are the head, lower extremities, upper extremities, rib, and abdomen.

The chiropractic manipulative treatment (CMT) CPT codes are:

98940: spinal, 1-2 regions

98941: spinal, 3-4 regions

98942: spinal, 5 regions

98943: extraspinal, 1 or more regions

Now let’s take a look at the use of modifiers 25 and 59 when reporting chiropractic services.

The general guidelines on reporting modifier 25 with CMT codes are as follows:

• CMT codes include a pre-manipulation patient evaluation.
• Additional evaluation and management (E/M) services may be reported separately using modifier 25, if the patient’s condition requires a separate E/M service, above and beyond the usual pre-service and post-service. So if manipulation and E/M codes are billed for the same visit, it is necessary to attach modifier 25 modifier to the E/M code.
• As the E/M service may be caused or prompted by the same symptoms or condition for which the CMT service was provided, different diagnoses are not required for the reporting of the CMT and E/M service on the same date.

The bottom line is modifier 25 should be used only when DCs perform an assessment above and beyond the adjustment.

The National Correct Coding Initiative (NCCI) edit program developed by the Centers for Medicare and Medicaid Services (CMS) is used by carriers and third party administrators in an effort to prevent improper payment when certain codes are submitted together. Modifier 59 and some other modifiers are exceptions to the NCCI PTP (procedure-to-procedure) edits.

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

CMS instructs that documentation should support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. Modifier 59 allows the claim to pass Medicare bundling edits, which would lead to additional reimbursement for the physician.

Chiropractic manipulative treatment codes – 98940-98942 – comprise three procedures, that is, pre-assessment (history), manipulation, and post-assessment, bundled together. These procedures cannot be routinely unbundled. If a distinct procedure is performed that is not inherent in the manipulation, a modifier should be appended to communicate to the carrier that an exception exists.

In January of 2015, CMS released new subsets of the 59 modifier, which may be used in place of it. These include modifiers XE, XS, XP, and XU. When providing services such as neuromuscular re-education (97112), massage therapy (97124), manual therapy or trigger-point therapy (97140), and billing Medicare, chiropractors should use the 59 modifier only as a “last resort”. Instead, they should consider using the XE, XS, XP, or XU subset, which would be much more appropriate. Let’s go over these subsets:

Modifier XE is a separate encounter—the service is distinct because it occurred during a separate encounter.

Modifier XS is a separate structure—the service is distinct because it was performed on a separate organ or structure.

Modifier XP, separate practitioner—the service is distinct because it was performed by a different practitioner.

Modifier XU, unusual non-overlapping service—the service is distinct because it does not overlap usual components of the main service.

In 2017, CMS provided the following example of modifier 59 usage. Let’s look at CPT codes 97140 and 97530 billed together:

97140 is a manual therapy technique. Examples are mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

CMS states that modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For e.g., one service may be performed during the initial 15minutes of therapy, and the other service performed during the second 15 minutes of therapy. The therapy time blocks may also be split. For e.g., manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy.

CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.

The bottom line is:

• Modifier 59 and other NCCI-associated modifiers should be only be used when appropriate and not just to bypass an edit.
• Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.
• Before using an NCCI-associated modifier, chiropractors should check with their local Medicare carrier for guidance.

I hope this helps, but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate  reimbursement for the procedures performed.

Thank you for listening!