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-59 Modifier Usage- Optum Provides Clarification on 97140

Payer Update

If you are expecting ground-breaking news, you won’t find it in this update. What you will discover is that Optum has finally taken the guesswork out of when and how to append the -59 modifier when performing CMT along with procedure code 97140 – manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction) on one or more regions (15 minutes each).

How would you answer these questions?

  • Have you received a request for records from Optum when performing CMT with procedure code 97140?
  • Have you received a denial when appending the -59 modifier to 97140 while performing procedure code 98941?
  • Do you use diagnosis pointers when listing the procedure code 97140? If so, are they pointing to the same diagnosis as the CMT?
  • Do you bill other payers 97140 with CMT but not Optum

If you answered yes to any of those questions you may want to pay particular attention to the coding guidelines from the April 2018 Optum CMT Reimbursement Policy. We have summarized the information below but encourage you to review the entire policy.

Current Procedural Terminology (CPT), NCCI & CMS

Listed below is a summary Optum’s policy:

Manipulation and Manual Therapy CPT code 97140 (Manual therapy techniques) may be billed on the same date of service as a CMT code when the manual therapy service is provided to a different, noncontiguous body region than the CMT…CMS has established the following four HCPCS modifiers (referred to collectively as –X{EPSU} modifiers) to define specific subsets of the -59 modifier: XE Separate Encounter; XS Separate Structure; XP Separate Practitioner; XU Unusual Non-Overlapping Service…The National Correct Coding Initiative (NCCI) Edits – developed by the CMS – provides guidance in the application of modifier – 59. Different diagnoses are not adequate criteria for use of modifier -59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed on different anatomic sites or during separate patient encounters…From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, the treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. [NCCI, 2017]

This means that you can append either the -59 modifier or the X modifiers; both are accepted forms of billing at this time. But what about the reference to noncontiguous body region? In order for us to understand Optum’s interpretation of body regions we should start with what is considered a “region” when reporting CMT. The policy says:

For the purposes of reporting CMT codes, there are five spinal regions and five extraspinal regions. The Spinal regions are: cervical (includes the atlantooccipital joint); thoracic (includes costotransverse and costovertebral joints); lumbar, sacral; and pelvic (sacroiliac joint). The Extraspinal regions are: head (including the temporomandibular joint, but excluding the atlantooccipital joint); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen.

Notice how Optum pulls it all together. Optum considers:

  • The treatment of myofascial structures using manual therapy techniques in the same organ (spine), where CMT was performed and was contiguous (cervical and thoracic), does not constitute treatment of different anatomic sites.
  • The treatment of myofascial structures using manual therapy techniques in the same organ (spine), where CMT was performed and was not contiguous (cervical and lumbar), does constitute treatment of different anatomic sites.
  • The treatment of the cervical spine and a shoulder joint does constitute treatment of different anatomic sites.

Now that you know the rules, if you are contracted with Optum (UHC) pay close attention to the following criteria in order to bill this procedure with CMT:

  • Manipulation was not performed to the same anatomic region or a contiguous anatomic region (e.g., cervical and thoracic regions were contiguous; cervical and pelvic regions were noncontiguous)
  • The clinical rationale for a separate and identifiable service must be documented (e.g., contraindication to CMT is present)
  • Description of the manual therapy technique(s) location (e.g., spinal region(s), shoulder, thigh, etc.)
  • Time (e.g., number of minutes spent performing the services associated with this procedure) meets the timed-therapy services requirement
  • CPT code 97140 is appended with the modifier -59 or the appropriate –X modifier

If you are billing 98941 along with 97140 you may find it very difficult to meet all of the criteria listed above. In addition to documentation, be sure your billing is consistent with the reason given for performing 97140 by pointing to the correct diagnosis code. The reason (diagnosis/condition) for performing CMT should never be the same as 97140 when billing. See a proper billing example below:

If, after meeting the contract criteria for billing, you are still receiving denials for performing 97140 with CMT, be sure to check out KMC University’s Billing and Collections Department, Classroom 6 Insurance Appeals and Reconciliation, Lesson 1 Appealing Denials. It contains several helpful appeal letters related to this topic. As always, KMC University recommends that you monitor the newsletters and reimbursement policy updates from all of your contracted payers. This is likely to have a domino effect on other major payers, so please, ‘heads up.’

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Posted by nuclearnetworking on Apr 16, 2020

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