Ambulatory Coding & Payment Report
Reader Question: OCE Edit 39
Question: We're getting outpatient code editor edit 39 (mutually exclusive procedure that would be allowed if appropriate modifier were present) and 40 (component of a comprehensive procedure that would be allowed if appropriate modifier were present) for several of our physical therapy and occupational therapy accounts. We are having problems with the following CPT codes: 97140, 97530 and 97116. Would it be appropriate to use modifier -59 on either of these if our documentation states that both procedures were performed, or are these truly mutually exclusive procedures?
Nevada Subscriber
Answer: According to CCI edits 7.1, 97530 (therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes) is comprehensive to 97116 (gait training [includes stair climbing]). Therefore, the service would not be separately identified unless each is distinct and independent from other services performed on the same day. If so, append modifier -59 (distinct procedural service). 97140 (manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes) does not appear as either comprehensive to or a component of 97530 or 97116. Its status would be decided by payer policy, so the -59 modifier might apply as well when billed with other services on the same dates.
- Published on 2001-07-01
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