The Physical Therapy Modifiers

The use of modifiers in insurance billing confuses many doctors and billers --- what modifier to use as well as when to use it. I have known many providers to make the same mistake: Put a modifier on the code, just to be safe! Well, sometimes adding a modifier without really knowing WHY can get you your payments, but if you do not document your areas of work, you could be in a lot of trouble come auditing day!
Here is a quick rundown on modifiers with a short description of each:

• 25: This is the Evaluation and Management modifier, E/M. This modifier is used when your evaluation is not a part of the normal beginning of the session---the "Hi, how are you doing?" part of the session---but when you evaluation is "significant and separately identifiable." This means taking more time than just 5 minutes to explain or discuss an issue. The 25 modifier is used with new patients, periodic reevaluations, re-injury, counseling (see the article to the left), release from active care, discharge. It is generally used when you perform a procedure on the patient during the same session as the evaluation. If you perform a procedure (as in Adjustment) on the patient on the same visit that you performs an exam and does NOT use the 25 modifier, you will not receive reimbursement from the insurance company.

• 21: This code is used only with the Evaluation/Management (E/M) codes. Modifier 21 signifies that the face to face provided is prolonged or otherwise greater than that usually required for the highest level of E/M service within a given category. This modifier is used when increased time is needed for a particular level of E/M service, without having the necessary clinical requirements for a higher level of E/M or a separate prolonged service add-on code.

• 51: Modifier 51 implies multiple procedures, when one or more procedure is performed on the same day. The 51 modifier is also used if the same procedure is performed on two separate parts of the body. A good example is an extremity adjustment performed on each wrist. You would bill 98943 for the first wrist and then 98943-51 for the second wrist. Do not use this modifier with 97010-97799 as these are multiple procedures by definition.

• 22: Use the 22 modifier when your service provided is "greater than" usually required. Some codes are segmented by time, and this modifier can be used if the time is greater than 1 unit but less than 2 full units. If the time requirement is 15 minutes, usually the minimum requirement for reimbursement for each unit of that particular procedure is 8 minutes. If the procedure takes 15 minutes plus 4 minutes, you can use this modifier to signify "more than" 1 unit, but “less than” two.

• 52: The opposing twin! The "less than" modifier. Use this one for REDUCED services. Under some circumstances, a service or procedure may be partially reduced or eliminated at your discretion. As an example, it can be used when not all views are taken on a "complete" x-ray series, yet no other CPT code fits the explanation of service. Another example is the physical therapy code 97110. If physical therapy is performed for 19 minutes, bill 97110 for the first 15 minutes, then bill 97110-52 for the remaining 4 minutes.

• 59: This modifier is used to distinguish that a particular service is distinctly separate from another. This is used for codes 97110, 97124, or 97140 when billed in conjunction with a Chiropractic manipulative therapy. The 59 modifier indicates that a procedure or service was distinct or independent from other services performed on the same day. Note that for 97140 to be paid, it not only needs a 59 modifier, but also must be performed in a separate region than the CMT service.

 

Disclaimer: This page is for information only and is not a coding or billing advice or guideline. PracticeSuite does not warrant or imply as to it accuracy or validity.