Occupational and Physical Therapy Providers

March 21, 2012

Some therapists are providing both group and individual therapy to a MaineCare member on the same date. If both codes are clinically appropriate and an appropriate National Correct Coding Initiative (NCCI) associated modifier is used, both services are eligible for payment. Supporting documentation must be in the beneficiary’s medical record.

For example, as explained by the Centers for Medicare and Medicaid Services (CMS), “modifier 59 can be used to identify procedures/services that are not normally reported together, but are appropriate under certain circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/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 provider. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

More coding information regarding NCCI edits is available on the CMS website. Scroll down to the Downloads section of the page and select “NCCI Policy Manual for Medicare Services - Effective January 1, 2012 [PDF/ZIP 602KB].”