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What Are Modifiers and Can They Help Maximize Your Billing?

As you run your physical therapy practice, not only must you guide your patients through recovery, you must work with insurance companies to be paid for your services. Sometimes it can feel like you’re beholden to insurers. That’s because so much comes down to billing codes.

When claims and billing are processed correctly, you get paid. When they’re incorrect, you have to wait longer to be paid (because the error must be fixed) or you lose some revenue outright on occasions. Insurance companies provide billing codes as a way to keep track of specific payables and services. A billing modifier is a critical coding component that allows you to show an insurer that a procedure or service you performed has been altered, due to specific circumstances, without necessarily changing its coding or definition.

Using modifiers appropriately can increase your revenue stream. The other side of the coin is that incorrect use can cost revenue and even lead to billing audits.

Let’s look at some of the key billing modifiers you may come across. Employing an outstanding PT billing service can make working with modifiers much easier and more successful.

Modifier 25

Billing modifier 25 has separate yet distinct uses, depending on whether a patient is new or established. It allows you to list significant and specifically identifiable evaluation and management coding services (E/M) on the same day of another treatment or procedure. But it can be used only with an E/M CPT code and your notes must state that the procedures were able to be identified separately.

Modifier 22

It is recommended that you don’t use this billing modifier. Doing so will most likely cause an audit. Use it only if there is no other code available to signify and identify the increased work you have performed. You will need to provide documentation that supports your findings and the need for the added services. It is important that you do not append modifier 22 to an E/M service.

Modifier 24

This one is used in conjunction with a physician’s services – specifically post-operative PT that does not related to the surgical procedure. In other words, an unrelated PT diagnosis. The doctor who performed the surgery must report that an E/M service provided by you was not related to the surgery itself. Your documentation must also specifically state that the performed E/M service is in no way related to the initial procedure. Reference the E/M code that accompanies the unrelated diagnosis on the claim you submit.

Used correctly, Modifier 24 can make it possible to increase revenue by being paid during the post-op period. If it’s used incorrectly, an audit may be triggered.

Modifier 79

This modifier can be used when you provide a service unrelated to a surgical procedure during the post-op stages. It must be used with modifiers 24 and 25 in the instance that you wish to also bill for an E/M service.

Modifier 57

This specific billing modifier relates to the decision for surgery. It takes over for modifier 25 when an E/M code results in a major procedure that requires surgical intervention. While that may not seem on the surface like it relates to PT, the aptly named “Global Surgery Policy” includes E/M services that were given the same day as, or the day after, a significant surgery. But modifier 57 can be used only with E/M codes 99201-99499.

Modifier 59

If you wish to earn extra revenue, billing modifier 59 may help. Use this modifier to identify non-E/M services that aren’t often used together, yet are appropriate. Your files must support such use. Unfortunately, roughly 40% of those using this code do so incorrectly, leading frequently to an audit. To use this modifier, four conditions must be met:

  • Use it only with procedure codes.
  • Procedure code to be separate from other services provided on the same day.
  • It’s an anatomical modifier.
  • It’s a multiple procedure modifier.

You must also append this modifier to the first CPT code.

Getting confused by all this? That’s understandable. Many PT practices have difficulties with these complex codes and billing modifiers. Consider hiring a PT billing and collection service to handle all of this detailed work for you, so you and your staff can focus on what you do best – helping patients.

Creative Commons Attribution: Permission is granted to repost this article in its entirety with credit to Jet PT Billing and a clickable link back to this page.

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      Optimal Physical Therapy

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      Lonoke Physical Therapy, Inc

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      Franklin Rehabilitation


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