Vol. 14 Issue 11
What's the correct use of CCI edits and modifier 59?
Q: My question relates to CCI edits and the use of modifier 59. Many of the codes used in rehab require a modifier and are listed in the National Correct Coding Manual with the indicator allowing a modifier to be used in order to differentiate between the services provided. When is it appropriate to use modifier 59 for treatment and procedures?
A :The Centers for Medicare & Medicaid Services (CMS) have two categories for correct coding initiative (CCI) edits. They're titled mutually exclusive and column 1/column 2.
Mutually exclusive is defined as codes that can't be billed together because they wouldn't normally be performed together. Examples of mutually exclusive codes include: manual therapy (97140) and therapeutic activities (97530); mechanical traction (97012) and manual therapy (97140); and group therapy (97150) and therapeutic exercise (97110).
Column 1/column 2 CCI edits are defined as codes in which one of the codes is considered a component of the more comprehensive code. Examples include: aquatic therapy (97113) and therapeutic exercise (97110); therapeutic activities (97530) and gait training (97116); and group therapy (97150) and self care (97535).
CMS recognizes that therapists may provide these services to the same Medicare beneficiary on the same date. It's not uncommon for a Medicare beneficiary to receive outpatient physical therapy services that consist of modalities or procedures that may be considered mutually exclusive of each other or a component of a more comprehensive code. For example, the patient may perform 25 minutes of aquatic therapy exercises under direct one-on-one contact of a therapist or therapist assistant, and then get out of the pool, shower, dress and perform 20 minutes of land-based exercises under direct one-on-one contact.
In this situation, therapeutic exercise is considered a component of aquatic therapy. In order to be reimbursed for the procedures, a therapist or therapist assistant needs to notify the billing department to append modifier 59 to therapeutic exercise. Using modifier 59 on therapeutic exercise lets Medicare know that the therapist provided these services on the same day to the Medicare beneficiary, but at separate and distinct times. Documentation needs to support that these services were provided at separate and distinct times.
The CMS question and answer section can be found at www.cms.hhs.gov/physicians/cciedits Click on NCCI FAQs to view Q&As.
Rick Gawenda, PT, is director of physical medicine and rehabilitation at Detroit Receiving Hospital in Michigan. He's also the owner of Gawenda Seminars and conducts national seminars on coding, documentation and reimbursement, along with other topics. He can be reached through his Web site at www.gawendaseminars.com
If you have a tough coding issue you can't crack, e-mail firstname.lastname@example.org. To read more coding suggestions, go to www.advanceweb.com/REHAB and click on the Coding Clues tool bar.