Why You Need Know About Modifier 59 When Submitting Bills To Insurance Companies

March 11, 2016 in

However, it seems as if our Honorable Judges are permitting insurers to deny payment if bills are sent in without the correct modifiers. Modifiers are a tricky area. Many have changed over time. Many are commonly used by medical practitioners. The Most important aspect of submitting your bills involves modifiers; MAKE SURE YOU USE THE CORRECT ONE!  Let us focus on the most common incorrectly used modifier.

What Is Modifier 59?

Why you should care about Modifier 59?

Modifier 59 is used to show the insurer that you performed 2 different services.

FOR EXAMPLE, You performed group therapy (97150) and direct, one-on-one, 15-minute therapeutic procedures (97110) and should therefore use modifier 59 to bill to distinguish the separate services in that they represent different sessions. (cms.gov)

Without Modifier 59:

You most likely will not receive reimbursement from the PIP carrier or from Medicare.

WHY?

Because you must show the insurer two different services were performed on the same day, and possibly to a different body region/anatomical site.

What Do I Use Modifier 59 FOR?

  1. Services rendered to your patients on different body regions/anatomical sites
  2. Services that are different from one; as mentioned above
  3. Same day services but different sessions; as mentioned above

What Is The Issue? I Know How To Use Modifier 59

As always, the Federal Government through the Center for Medicare services added four new crazy-looking modifiers. These new modifiers are as follows:

  • XE- Same day services but different sessions; as mentioned above
  • XS- Services rendered on different body regions/anatomical sites
  • XP-Services performed by a different practitioner
  • XU- Unusual service that does not use the same components of the main service.

Why these letters?

Federal Government/CMS was concerned with curbing fraud. They opined that modifier 59 was the most incorrectly used and abused.

However, Modifier 59 is used to distinguish between services, body parts, and encounters.  Moreover, insurers should read all SOAP notes/doctor’s summaries they receive. The SOAP notes should contain all relevant information supporting the modifier of choice. This new coding subset seems like another roadblock to deter medical providers from billing too many services in one day.

Bottom line, the “X” codes replace 59.  Get familiar with them and use them for optimum reimbursement.

Ask the US

The PIP team at the LaBovick Law Groups provides free PIP services. We will give you the most current information you need to receive proper reimbursement for services rendered. We provide a five-year historical review of your MVA patient files.  We likewise litigate your files free of charge.  IF you think you are being incorrectly paid or have any questions about PIP, call us!