An effort to decrease abuse of illing for procedure codes, the National Correct Coding Initiative CI) edits were developed by the Centers for Medicare and Medicaid Services (CMS).
The NCCI edit program is used by carriers and third party administrators in an effort to thwart abusive billing practices of codes that should not be used together.
For doctors of chiropractic, three common therapeutic procedure codes are identified by the edits when billed with chiropractic manipulative treatment (CMT) codes: 98940, 98941, and 98942. These procedure codes are 97112 neuromuscular re-education, 97124 massage therapy, and 97140 manual therapy.
There are exceptions to the NCCI edits. One is when the 59 modifier is used to indicate to the carrier that a “distinct procedural service” is involved and the procedures should be paid separately. Unfortunately, the 59 modifier is also an oft-abused and erroneously used modifier. This prompted CMS to release new subsets of the 59 modifier in January 2015.
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non- evaluation and management (E/M) services performed on the same day. Modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.
Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
When another already-established modifier is appropriate, however, it should be used rather than modifier 59. If no further descriptive modifier is available, and the use of modifier 59 best explains the circumstances, only then should modifier 59 be used.
Direction on the use of X-subset modifiers
In January 2015, CMS released direction on the use of the X-subset modifiers. The X subsets are expected to have initially only limited effect on chiropractic procedures and billing. Although the X subsets apply only to Medicare billing as of the beginning of 2015, it is expected that the X subsets will be adopted by other carriers because of the data indicating 59- modifier abuse. If this occurs, it will greatly affect chiropractic billing for reimbursement with the above mentioned therapeutic procedure codes.
The chiropractic manipulative treatment codes (98940, 98941, and 98942) consist of three portions or procedures bundled together. These are the pre-assessment (history), the manipulation, and the post-assessment. These procedures are inherent and cannot be routinely unbundled. If DCs are performing a distinct procedure that is not inherent in the manipulation, then they have to append a modifier to communicate to the carrier that an exception exists.
It was a controversial decision when NCCI edits deemed services such as massage and trigger-point therapy to be a bundled procedure with manipulation. The edits contend that procedures such as massage prepare the patient for manipulation and are therefore not separately billable. Many carriers do not abide by this policy, but others do.
The American Medical Association (AMA) stated in March 2006, in CPT Assistant, that 97110–97124 represent distinctly separate and unrelated procedures not considered inclusive of the CMT described by 98940–98943. According to the AMA, separate body regions are not required. Note that 97140 was not mentioned in the CPT Assistant article, and as such it is generally accepted that this procedure is included with a CMT code when performed at the same encounter.
Per NCCI edits, 97112 neuromuscular re-education, 97124 massage, and 97140 joint mobilization require a 59 modifier if performed at the same encounter as a chiropractic manipulation. If the 97140 is performed on the same region the same day, then not only will the carrier not reimburse for both procedures but the provider cannot bill the patient for both procedures either.
However, if the payer follows AMA guidelines, 97112 and 97124 do not need to be in a distinctly separate region, yet they still need the modifier if the payer follows NCCI edits.
Although neuromuscular re-education, massage, and joint mobilization are not reimbursable by Medicare when performed by a chiropractor, if the patient needs the claim to be processed and denied by Medicare to be sent to a secondary carrier, the claim must be submitted to Medicare first. That is when the X subsets come into play.
Also, to ensure that medically necessary services are performed, the provider must document: 1. That the exception exists, 2. The regions where the services were performed, and 3. The diagnosis for each region. Therefore, the X subsets must be used.
When performing neuromuscular re-education, massage, joint mobilization, or trigger-point therapy and billing Medicare, the 59 modifier is to be used only as a “last resort.” Instead, one of the following XE, XS, XP, or XU subset modifiers would be more appropriate.
- Modifier XE: Separate encounter—the service is distinct because it occurred during a separate encounter.
- Modifier XS: Separate structure—the service is distinct because it was performed on a separate organ or structure.
- Modifier XP: Separate practitioner—the service is distinct because it was performed by a different practitioner.
- Modifier XU: Unusual non-overlapping service—the service is distinct because it does not overlap usual components of the main service.
The XS modifier will most likely be used in most circumstances for 97140, but XU may be most appropriate for 97112 and 97124, as they do not need to be performed on a separate structure. But this depends on guidance from payers.
Check with your local Medicare carrier for further clarification. Do not use these new modifiers for private payers until it is confirmed that they have begun to accept them. Some have stated that they will allow either the 59 modifier, or one of the X modifiers, but not both. Others have indicated that they would like to see the 59 modifier followed by the appropriate X modifier on the same line. Yet other carriers have remained silent.
Further clarification is expected from Medicare, and private payers will probably follow suit.
Modifiers are appended to HCPCS and CPT codes when clinical circumstances justify their use. The X-subset modifiers are an important tool in clarifying your claims for reimbursement. The modifiers are not there to deny claims but rather to get them paid when used properly.
Mario Fucinari, DC, MCS-P, CIC, CCS-P, presents classes and webinars to aid doctors and their staff in correct compliance procedures. He is the author of several books, including ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office. He can be contacted at firstname.lastname@example.org or through askmario.com.
Evan M. Gwilliam, DC, MBA, CPC, NCICS, CCPC, CCCPC, CPC- I, MCS-P, CPMA, is a vice president and director of education and consulting for the ChiroCode Institute and is the only chiropractor certified by the AAPC as an ICD-10 trainer. He can be contacted at email@example.com.