How to Use Modifier 59 With the New PT and OT Evaluation Codes

Whether you’re a therapy billing newbie or a seasoned vet, knowing the ins and outs of modifier 59—and when it’s appropriate to bill with this “last resort” modifier—can be difficult and just plain confusing. With CMS’s recent release of new eval and re-eval CPT codes, your confusion may be intensifying. But, don’t let this weighty topic keep you up at night. Instead, look to the information below to fine-tune your billing and documentation efforts.

Proper Use of Modifier 59

As I touched on above, modifier 59 isn’t some across-the-board free pass to higher reimbursement. There are hard and fast rules about its application. Essentially, if you want to avoid a potential claims audit, modifier 59 should be the exception—not the rule. So, when can you use it? Here are the criteria for proper modifier 59 use:

You must perform services that are considered separate and distinct.

According to this WebPT Blog post, “under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances.”

You must bill for services that form edit pairs.

Rehab therapy providers can also use modifier 59—specifically, in conjunction with NCCI edit pairs. So if you, the PT, bill two codes that are considered a linked pair, you’ll receive payment for only one of those codes. That is, of course, unless you determine that you performed the services separately and independently of one another—in which case you can affix modifier 59 to the claim and receive separate payment for each procedure.

You should only use this modifier when there isn’t a better option.

That said, modifier 59 shouldn’t be your go-to option for securing separate payment for linked services. Instead, as the CPT manual states, “when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” To that end, CMS created a new set of modifiers—XE, XP, XS, and XU—for providers to use in place of modifier 59, when appropriate. However, therapists should hold off on using these new modifiers until further notice.

CCI Edit Pairs for the New PT and OT Evaluation Codes

As of July 1, 2020, the new PT and OT evaluation codes—97161 to 97163 for PTs and 97165 to 97168 for OTs—no longer form NCCI edit pairs with other commonly used PT and OT codes. That means PTs and OTs can bill for evaluative services in conjunction with other therapy services without needing to apply modifier 59—for Medicare, anyway. Some commercial payers may have their own requirements. (You can read more about this change in this blog post.)

As with all regulatory changes, though, it may take some time for MACs to update their systems. If you’re experiencing Medicare claim denials as a result of omitting modifier 59 from claims that include, say, 97163 and 97140 (which previously formed an edit pair that required modifier 59), we recommend appealing the denial.
Looking for the most common NCCI edit pairs for rehab therapists? Download your free copy of this chart to see which commonly used code pairs still require modifier 59.

2021 Changes

If you’ve been keeping tabs on the NCCI edit pairs for a while now, then you may notice that there are several prior NCCI edit pairs missing in 2021. That’s because CMS—at the behest of the APTA—has agreed to accept these pairs without the use of a modifier. In other words, you can perform the following services—and receive payment for them—without needing to affix modifier 59:

• 97110 with 97164
• 97112 with 97164
• 97113 with 97164
• 97116 with 97164

• 97140 with 97164
• 97150 with 97164
• 97530 with 97116
• 97530 with 97164

• 99281-99285 with 97161-97168
• 97161-97163 with 97140
• 97127 with 97164
• 97140 with 97530
• 97530 with 97113

What challenges have you previously run across with modifier 59? What strategies do you plan on deploying to ensure you receive the payment you deserve? Leave your thoughts in the comment section below.