Our previous way of handling the process of adding 59 modifiers to charges in TheraOffice was through our CPT checks. The CCI edits were all loaded into the default database and when any of the combinations were hit when suggesting charges, we would warn the therapist that CCI edits existed and a 59 modifier was needed.
While most clinics were fine having their providers add these modifiers, it did open up the possibility of someone missing the popup. To shore up our process on this, we built a new feature called Charge Check Exceptions. On any client after the .8.4 version, a separate check would be made using our own list of CCI edits. If we found any hits, we would automatically add the 59 modifier to the charge after the charge check exceptions screen populated. Regardless of what they did, we would make sure that 59 modifier was added. In its current form, this new feature only works with 59 modifiers, though we do have future plans for expansion into other areas.
The following is an example scenario when patient John Smith came in for a physical therapy visit on 5/1/2018. The PT suggests the following charges:
After the therapist suggests charges, the following CCI edit is found:
The Charge Check Exceptions box will immediately populate and acknowledge that the second billable code in Column 2 requires the addition of a modifier.
Once you review the information and click “OK”, the necessary 59 modifier will automatically populate within the appropriate MOD column of the correct charge.
Aside from the addition of 59 modifiers, there are other reasons to have charge checks in place, and for this reason, we did not remove the existing CPT Checks feature.
Charge Check Exceptions and CPT Checks run in tandem. When the same CPT combination appears in both checks, we give priority to the CPT Checks, meaning the automatic addition of a 59 modifier through a Charge Check Exception will NOT take place. This may seem strange at first, but there is a good reason behind it. Some insurances have decided that a 59 modifier is not good enough, and they will not pay on that CPT code combination even if a 59 modifier is added. In those instances, we have to allow clinics to prioritize putting in a CPT check for that insurance that says something like “Cannot Bill This CPT Combination”.
What this priority also means is that to get automatic 59 modifiers across your insurances, a clinic must go into the CPT Check, edit the rule group, and then remove the individual rules for adding 59 modifiers / CCI edits.
Additionally, you have the option disconnecting the CPT Check from specific insurances altogether by navigating to the “Manage” tab in the backstage menu, clicking on “Insurances”, and then editing the particular insurance in question. From there, click on the “Charge Checking” tab and disable the CPT Check group from the insurance. Doing so will make sure that priority is always given to our automatic process.
While CCI edits started as a program for Medicare and Medicaid, over the years, most commercial insurances have adopted the same set of rules. For this reason, the Charge Check Exceptions feature triggers for all insurances.
We have not seen any instance of an insurance denying for the specific reason of there being a 59 modifier on a charge. Including the 59 modifier is just better coding practices, even if the insurance does not specifically require that you include it. If your clinic already has a good handle on 59 modifiers, this will not interrupt anything you are currently doing. It will only add to it.