What Are The New Subsets of Modifier 59

March 8, 2015
Rick Gawenda

Modifier 59 is used in the outpatient therapy setting to identify when one intervention was provided at a separate and distinct time from another intervention to the same Medicare beneficiary during the same treatment session. Modifier 59 is not only the most commonly used modifier, but is also the most abused modifier that is utilized. Due to this, the Centers for Medicare and Medicaid Services (CMS) has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier). The effective date of the new subsets of modifier 59 was January 1, 2015; however, CMS has not yet mandated their use. The new subsets of modifier 59 along with the definition of each are as follows:

The content here is for members only log in here or sign up.

All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.

This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

  1. I am an SLP and have been to a seminar of yours a few years back. I am going to join as a Gold Member after this email!
    The hospital that I am currently working for is putting pressure on me to see my patients, that are in an outpatient hospital setting, twice a day, for 2 distinct therapy sessions, and then bill for the 2 separate sessions even though they are untimed codes. For example, if I see a patient at 10-10:30 for 92507, and then see them again at 1-1:30, they want me to bill for 2 units since they were separate sessions. I find this unethical for a few different reasons, and not sure if I really can bill for it. I can’t find anything on the ASHA website that supports or disputes this. On the inpatient rehab floor, as well as the acute side, they do this all the time…I am not even sure that is appropriate. Please help ASAP! I am about to resign due to this issue.

    1. That is up to you, the clinician, to decide the frequency and duration of therapy services. Inpatient rehab and acute care is not paid on a per CPT code basis. Patient’s on the IRF unit require 3 hours of therapy per day at least 5 out of 7 days and acute care is paid via DRG’s.

    1. CMS has not yet announced an implementation date for the new subsets of modifier 59 for outpatient therapy services.