# PT and 59 modifiers



## jmcpolin (Jan 31, 2012)

Any help on this would be greatly appreciated per Medicare guidelines it looks as if we bill 97110 and 97150 together we need to add a 59 modifier to both CPT codes this makes no sense to me.  Below is the Medicare guidelines.

Medicare Guidelines
6. Group and Individual CPT Codes Billed on Same Day:

Billing for both individual (one-on-one) and group services provided to the same patient in the same day: This is allowed, provided the CPT and CMS rules for one-on-one and group therapy are both met. However, the group therapy session must be clearly distinct or independent from other services and billed using a -59 modifier. The group therapy CPT code (97150) and the direct one-on-one 15-minute CPT Codes for therapeutic procedures (97110 - 97542) are subject to Medicare's National Correct Coding Initiative (NCCI). The NCCI edits require the group therapy and the one-on-one therapy to occur in different sessions, time frames, or separate encounters that are distinct or independent from each other when billed on the same day. The therapist would use the -59 modifier to bill for both group therapy and individual therapy CPT codes to distinguish that the two coded services represent different sessions or separate encounters on the same day. Without the -59 modifier, payment would be made for the lower-priced group therapy CPT Code, in accordance with CPT/CCI rules. The CCI edits are based upon interpretation of coding rules.


----------



## btadlock1 (Jan 31, 2012)

jmcpolin said:


> Any help on this would be greatly appreciated per Medicare guidelines it looks as if we bill 97110 and 97150 together we need to add a 59 modifier to both CPT codes this makes no sense to me.  Below is the Medicare guidelines.
> 
> Medicare Guidelines
> 6. Group and Individual CPT Codes Billed on Same Day:
> ...



The edit shows 97150 in column 1, and 97110 in column 2, with status indicator "1", on the mutually exclusive table. 
So, if the patient is having group therapeutic procedures, and they also have an individual therapeutic procedure (or vice-versa...I don't know of a good example - sorry), you can report both, as long as they didn't occur simultaneously - you can't get paid twice for doing one service, by reporting it as group and individual, but as long as 97110 meets the requirements to use modifier 59 (a different type of procedure should suffice), then you should be able to report it. Just make sure that the physician or therapists' one-on-one patient contact is evident in the documentation, for the individual service. Hope that helps!


----------



## jmcpolin (Jan 31, 2012)

My thought was to add the 59 modifier to 97110 but if you read the guidelines it says to bill97150-59
97110-59

That makes no sense to me


----------



## btadlock1 (Jan 31, 2012)

jmcpolin said:


> My thought was to add the 59 modifier to 97110 but if you read the guidelines it says to bill97150-59
> 97110-59
> 
> That makes no sense to me



Is this what you're referring to?:
"...The therapist would use the -59 modifier to bill for both group therapy and individual therapy CPT codes to distinguish that the two coded services represent different sessions or separate encounters on the same day..."

They're not saying to use a 59 on both services, but to append it to one of the services, if both are done on the same date - it's not worded well, though - I can definitely see where you're coming from. According to this guideline, you'd append the modifier to the group code only:

"However, the group therapy session must be clearly distinct or independent from other services and billed using a -59 modifier."

My apologies - I missed that earlier. Usually, the column 2 code in an NCCI code pair edit, is the one that gets the modifier; but, that's not always the case. This would be an example of the exception to the rule, I suppose. But, no, you shouldn't append it to both, if those are the only services being billed; only one of them needs to be identified as a 'distinct procedural service', with a modifier, because it's implied: if you have 2 services billed, and one is _definitely_ distinct from the other, then logically, both services must be distinct from one another. Make sense?


----------

