Your physical therapy (PT) costs may be $15 to $19 per visit higher than they should be. Here’s what’s going on:
It’s common for therapists to perform multiple procedures at the same time on a single body part. Under nationally accepted standards (under the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative), the therapist is to be reimbursed for only one of these procedures. Sometimes, it is appropriate for the PT to bill for multiple procedures -- for example, if two procedures commonly done simultaneously are performed at separate times. But, unless the therapist adds a special modifier to the procedure code, only one will be reimbursed.
If multiple procedures are to be reimbursed, the "59 modifier" is added to the end of the CPT code, and the treating provider documents the reason for the variance in coding in the medical notes. The 59 modifier should be on about 11% to 15% of lines on PT bills.
But some payers are seeing 59 modifiers on almost ALL BILLS. It appears the 59 modifiers were not added by the therapist; they were added by a PT network company.
There’s no explanation in the treatment notes for this billing practice; no evidence the affected procedures were actually performed at separate times; no indication the PT network company reviewed the treating provider’s notes prior to upcoding. No documentation, no record, no history.
It appears that the intermediary was adding the 59 modifier as an automated system edit without reviewing the treatment notes. The systemic upcoding has resulted in higher costs for payers.
You should look at bills processed between 2009 and 2014:
- If more than 20% of lines on your PT bills have the 59 modifier, you MAY have a problem.
- If more than 40% of the lines on your PT bills have this modifier, you DO have a problem.
