The Most Common Modifier for Acupuncture Claims

Q: I am having problems getting claims paid and it appears to always be related to needing to use a modifier. I am not sure which modifiers I should be using, is there any way you can provide a common list?

You are not alone as many providers will have denials related to lack of, or improper use of a modifier. Here is a primer on the use of modifiers in an acupuncture setting. There are many modifiers but only two are commonly needed for acupuncture billing.

Level 1 Modifiers

Current procedural terminology (CPT) modifiers (also referred to as Level I modifiers) are used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by an acupuncturist. Code modifiers help further describe a procedure code without changing its definition.

CPT coding modifiers are used to communicate that something is atypical about a particular claim. Circumstances when a modifier should be used include, if the service: (a) has been increased or decreased; (b) has both a professional and technical component; (c) only part of the service was performed; (d) an independent or adjunctive procedure was performed; (e) if unusual events occurred; and (f) is expected to be denied as not appropriate and/or necessary.

At the end of the day, a modifier is simply an added 2 character (can be numbers or letters) appendage to a CPT code to provide special information about the service.

The most common modifier for acupuncture claims is modifier 25. This modifier is appended to the evaluation and management (E&M) code 99201-99215, to indicate the E&M being reported is separate and distinct from the inherent evaluation associated with the acupuncture services or other treatment of the day.

Anytime you are billing an E&M the same date with treatment the E&M must have a 25 modifier otherwise the E&M code will be denied as inclusive to the other services provided. By example, the date of service with a detailed exam and acupuncture would be coded in this manner 99203 25 with 97810.

Modifier 59

Although not common for acu-puncture another modifier that may be needed in some instances is modifier 59. This modifier is to be appended to physical medicine codes, specifically procedures when done on the same visit. For instance, if providing exercise 97110, therapeutic activities 97530 or neuromuscular re-education 97112 on the same visit. Those codes would (if used together) be appended with 59 to demonstrate that service was separate and distinct.

According to CPT definition and guidelines of 59, under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances. Though this modifier is common for chiropractic providers (whom you may get advice from) it is not common for acupuncture.

Modifier -59 indicates that the procedure represents a distinct service from others reported on the same date of service. This modifier was developed explicitly for the purpose of identifying services not typically performed together.

Also for VA claims under the PC3 program, or VA Choice there is a modifier requirement for physical medicine coding. If a claim is made to the VA, that includes physical therapy services, it must include the proper modifier or the claim will be rejected.

This modifier is GP. When coding physical medicine codes 97010-97799 to the VA they must have GP. According to the Centers for Medicare and Medicaid Services (CMCS), a GP modifier means that services are delivered under an outpatient physical therapy plan of care and required on these federal claims. Failure to add the modifier will result in a denial of the physical medicine services even though they are authorized.

A frustration in billing is that a denial will state there is an improper (or missing) modifier but when you inquire as to what the modifier is they will not inform us of such, as insurance does not provide billing advice.

Best wishes and success and hope this primer gives you a leg up on billing and coding.