Medical Billing Forum
Coding => Coding => : RachelMBS March 14, 2014, 03:50:04 PM
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I bill for a PT practice who use 97140,97530 all the time. I know 97530 needs a 59 modifier to unbundle the codes. Every insurance pays, except for Oxford. they bundle the codes. It is on every claim. Why are they the only one doing this? Are there any other codes that can be used to separate them. Or any other CPT :-[ >:(
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Sorry.. Familiar with PT but not this insurance. Let me see if I can check with someone else.
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Asked 2 people but neither bill Oxford.
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Sounds like NCCI edit as those are bundled codes.
Can't explain why others may pay but sounds like Oxford (UHC) is following NCCI
http://www.webpt.com/blog/post/modifier-59-distinct-procedural-service
NCCI states 95851, 95852, 97002, 97004, 97018, 97124, 97530, 97750, and 99186 are all linked services when billed in combination with 97140. So, if you bill any of these codes with 97140, you’ll receive payment for only 97140. Medicare actuallyuses this example on their site for therapists regarding appropriate use of modifier 59.
CMS states that when billing a 97140 and 97530 (therapeutic activities; direct, one-on-one patient contact by the provider; use of dynamic activities to improve functional performance; each for 15 minutes) for the same session or date, modifier 59 is only appropriate if the therapist performs the two procedures in distinctly different 15 minute intervals. This means that you cannot report the two codes together if you performed them during the same 15 minute time interval.
Thus, if your care meets that standard, you can add a modifier 59 to 97530 to indicate it was a separate service and should be payable in addition to the 97140. The same holds true for billing 97140 with 95851, 95852, 97002, 97004, 97018, 97530, or 97750. However, you can never bill 99186 or 97124 with a 97140—you cannot add any modifier to change this because these codes are mutually exclusive procedures, according to CMS.
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