Health Information Management

Should you override that outpatient therapy NCCI edit?

JustCoding News: Outpatient, March 24, 2010

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When an outpatient physical therapist provides exercise using land- and water-based therapy to the same patient on the same day, the therapist will have to decide how to bill for the encounter(s) based on whether he or she performed the procedures at distinctly different times.

Such therapies are considered edited pairs and are not billable on the same date of service unless the provider appends modifier -59 (Distinct procedural service) properly. “One of the uses for this modifier is that it indicates that the procedure or service was distinct or independent from other services performed on the same day,” says Mary R. Daulong, PT, CHC, owner and president of Business & Clinical Management Services, Inc., in Spring, TX.

Therapists sometimes have a legitimate reason for providing both services. Sometimes a patient has more than one diagnosis, such as a shoulder problem and a knee problem. The therapist may address the shoulder problem with a land-based exercise, whereas the knee problem may be susceptible to impact or post-surgery stressors and thus require the buoyancy of a water-based program.

“A lot of times, aquatic therapy and land therapy [billed together on the same day] are not going to be paid unless you add modifier -59,” says Joanne Byron, LPN, BSNH, CHA, CMC, CPC, MCMC, PCS. Byron is board chair of the American Institute of Healthcare Compliance, Inc., in Medina, OH, and also a senior consultant at Health Care Consulting Services, Inc.

But when is it appropriate to append modifier -59 to override the edits?

Purpose of NCCI edits

First, you need to understand the purpose of the National Correct Coding Initiative (NCCI) edits. CMS introduced NCCI edits for outpatient therapy in 1996 to prevent improper payment when providers report incorrect code combinations. These edits apply to code combinations in which one of the codes may be a component of a more comprehensive code or when a code is mutually exclusive of another code in the pair.

Staying abreast of the changes to the NCCI edits is important, Byron and Daulong say. CMS updates the edits quarterly, so someone at your facility should be monitoring them. Although the resources of professional organizations are very helpful, Daulong cautions against relying solely on them. “Your services might be somewhat different, and you may be looking for different codes,” says Daulong.

The NCCI edits are displayed in two sets of tables, both of which have two columns. The first table, “Column 1 & Column 2,” lists CPT codes under Column 1 that are considered to be comprehensive services, whereas Column 2 lists CPT codes considered to be included in the comprehensive services listed in the corresponding rows in Column 1.

Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits in this table, Byron says. “The code pair edits may simply represent two codes that should not be reported together. The edit allows payment for the Column 1 code only,” she says.

The same holds true for the second table, titled “Mutually Exclusive Edits.” These edits allow for payment only for the Column 1 code unless you correctly append modifier -59.
The edits also include one of the following NCCI modifier indicators:

  • 0—No modifier allowed under any circumstance, and the code pair will not be paid separately
  • 1—Modifier -59 allowed in order to differentiate between services provided; allows for separate payment when used correctly
  • 9—No modifier needed because the edit is inactive as of the posted date, and services may be separately billable

Examples of NCCI edits

NCCI edits also can apply to codes 97116 (therapeutic procedure, one or more areas, each 15 minutes; gait training [includes stair climbing]) and 97530 (therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes).

Therapeutic activities to improve functional performance can include stooping, bending, crouching, lifting, and kneeling, Daulong says. It can also include walking activities such as learning to balance when turning. The same patient may undergo gait training to relearn to walk safely and efficiently following hip surgery. Because the therapist performed the services at separate and distinct times, you may append modifier -59, Daulong says.

The NCCI edit with Column 1 CPT code 97140 (manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes) and Column 2 CPT code 97530 (therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes) is often bypassed by using modifier -59, Byron says. You should only bypass the edit when the therapist performs the two procedures in distinctly different 15-minute intervals.

“The two codes cannot be reported together if performed during the same 15-minute time interval,” Byron says.

In general, providers should not report more than one physical medicine and rehabilitation therapy service for the same 15-minute time period, Byron says. “The only exception involves a ‘supervised modality’ defined by CPT codes 97010–97028, which may be reported for the same 15-minute time period as other therapy services,” she says.

Some CPT codes for physical medicine and rehabilitation services include an amount of time in their code descriptors. Certain NCCI edits pair a timed CPT code with another CPT code (timed or non-timed). Therapists and coders can bypass the edits with modifier -59 when the therapist performs the two procedures in a code pair edit in different timed intervals, even if sequential during the same patient encounter, Byron says.

Modifier -59

Incorrect use of modifier -59 can lead to big trouble. Therapists and coders may overuse it because they don’t understand the definition of separately identifiable, Byron says. But not reporting the modifier when it is appropriate “will result in bundling of services, leading to a great loss of revenue in your therapy department,” she adds.

In addition to ensuring that your documentation supports the use of modifier -59 to bypass an edit, be sure to append the modifier to the correct code. If you affix modifier -59 to both codes, you may be subject to denial of payment for both procedures, Daulong says. Modifier -59 always goes on the code listed in Column 2. If you report the modifier with the wrong code, you risk incorrect reimbursement—more or less than what you’d otherwise receive.

Daulong also recommends having the therapist be the one to append modifier -59. “In my opinion, only the therapist can attest in their documentation that activities occurred at different times,” she says.

Editor's note: This article was originally published in the April issue of Briefings on APCs. E-mail your questions to Managing Editor Michelle Leppert at

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