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MediCAre Advisor
Proper use of Modifiers
By Pauline M. Franko, PT, CEEAA
QuesTioN: Must a 59 modifier be used every
time when billing 97140 and 97124 together?
ANswer: the 59 modifier is used as part of the
Correct Coding Initiative (CCI) to identify that
the practitioner provided “distinct procedural
services” when 2 CPt codes listed as part of the
CCI edits are performed by the same practitioner
on the same day. Recently, CMs merged the
2 listing of the edits, the Column 1/ Column
2 correct coding edits and Mutually exclusive
coding combinations into 1 integrated system.
the CCI edits were initially designed to prevent
unbundling of services, believing that one
CPt code was actually part of a more comprehensive
code and therefore, the practitioner
was already getting reimbursed for the lesser
service with the comprehensive code. the
system did allow for use of the 59 modifier
when the documentation supported that the
2 codes billed were distinctly different from
one another.
Based on that explanation, the CPt code
97140 describes the use of manual therapy
procedures, including techniques of mobilization/manipulation,
manual lymphatic drainage
and manual tractions. when billed, the
documentation should clearly describe the
specific techniques used along with the body
part treated. CPt code 97124 describes the use
of massage including effleurage, petrissage
and/or tapotement (i.e., stroking, compression,
percussion). Again, to bill this code, the documentation
should support the use of massage
for the condition being treated, identify the
techniques used and the body part treated.
If this is done, then the 59 modifier is added
to the code to indicate that the CCI edits are
being used and the contractor should pay for
the lesser code.
By adding the 59 modifier to the claim, the
practitioner is attesting that there is documentation
in the medical record supporting
the two codes. However, if these services are
provided on different days, then the modifier
is not required. n
[MANAgEMENt FoCus]
disclaimer: The answers provide are based on
Medicare guidelines for what is payable under
the Medicare Part A and Part B Benefit. As
always, the provider should be aware of the
other regulations that might supersede the
Medicare payment guidelines such as the state
Practice Act and the state Administrative Code.
in any scenario, the practitioner must go with
the most stringent requirement in order to be
compliant. The information provided is current
as of the time of publication.
Pauline M. Franko is owner of Encompass
Consulting & Education, LLC based in Tamarac,
FL. The company specializes in Medicare
Seminars and Webcasts as well as Consulting
and Compliance Training. To learn more visit
www.encompassmedicare.com. The company’s
“Direction on Demand” service specializes in
providing the rehabilitation professional with
a clear, easy way to understand how to provide
Medicare compliant services to their patients in
the SNF and outpatient settings. Contact the
author through the Encompass website or by
phone at 954-720-4087.
ADVANCE for Physical Therapy & Rehab Medicine
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