I promise your eyes will NOT glaze over – but you need to know what’s going on in the arcane world of procedure coding. Why?
Because your PT costs may be $15-$19 per visit higher than they should be. And the savings your vendor is touting might be even more inflated.
Here’s what’s going on – and remember, this is specific to PT.
It’s common for therapists to perform multiple procedures at the same time – on a single body part. There’s a list of procedures that are commonly performed together, and unless the therapist adds a specific modifier to the procedure code, only one will be reimbursed.
Nationally accepted standards (under CMS’ National Correct Coding Initiative) allow the therapist 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 and distinct times.
In this circumstance, the treating provider documents the reason for the variance in coding in the medical notes. On the bill, the “59 modifier” is added to the end of the CPT code to indicate that the code should be paid.
Hang in there – almost done…btw there’s a good overview of the latest info on this courtesy of medical bill review company Equian here…
National average statistics (from two HSA customers I’ve been working with on this) indicate the 59 modifier should be on about 11%-15% of lines on PT bills.
Which brings me to the crux of the matter. Some payers are seeing 59 modifiers on almost ALL BILLs. After a lot of research, digging thru billing data, and back-and-forth with therapists and PT networks, it appears the 59 modifiers were NOT added by the therapist; they were added by a PT network company.
Further, there’s no explanation in the treatment notes for this billing practice; no evidence the affected procedures were actually performed at separate and distinct 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. Without putting too fine a point on this, the systemic upcoding has resulted in higher costs for payers, along with significantly exaggerated savings as the bills show higher billed charges.
Perhaps there is a perfectly reasonable explanation for this, however I’ve not heard one to date. And the coding experts I’ve spoken with can’t seem to come up with one either.
Let me be clear – this is specific to the use – appropriate, inappropriate, or questionable – of the 59 modifier, and only the 59 modifier. Ongoing research has not turned up other billing-related issues.
What does this mean for you?
You need to ask your billing folks to review their PT billing data to determine if:
- You’ve been paying too much for PT
- You have made decisions on PT vendors based on inaccurate information
- Your employer clients have been billed for too much PT, and paid too much for managed care services.
How will you know if this is a problem?
Look at bills processed between 2009 and 2014 -
- If more than 20 percent of lines on your PT bills have the 59 modifier, you MAY have a problem.
- If more than 40 percent of the lines on your PT bills have this modifier, you DO have a problem.
What do you do if you think you’ve got a problem?
- Ask your PT network/billing intermediary to explain, and require them to show why they are adding the modifier and how they are justifying doing this without reviewing the treating provider’s bills.
That will be a very interesting conversation…