After hours of research, our team has concluded that carriers will likely continue to disallow PMR modalities rendered by LAcs – even when following the guidelines to the letter – because LAcs were never an approved provider type for these CPTs.

That being said, we do not mandate coding strategies for our clients. Should you wish to continue billing these modalities, these are the guidelines for the required documentation that accompanies use of these codes and modifiers GP & 59.

Per CMS guidelines, all PMR modalities require documentation (chart notes)

Now, it seems the major commercial carriers are finally enforcing this guideline. Here are some tips on documenting your services correctly to get paid and avoid needless denials and audits.

General modality coding and documentation guidelines:

All modalities must be shown to be medically necessary and consistent with the chief complaint, diagnoses, and treatment plan. Documentation must include the rationale for each therapy and must clearly establish the medical necessity for each modality that is billed.

Required details checklist for ALL modalities:

• Include treatment plan with specific, documented objective treatment goals
• Rationale for service, including use of and purpose for modifiers
• Specific region(s) treated
• Setting, frequency, and/or type of device used (if applicable)
• If time based CPT, indicate start/end times

In addition to the general guidelines for documentation, there are some CPT and modifier-specific requirements as well.

Modifier GP

CPT codes 97016, 97110, 97124 & 97140 are considered “always” therapy services and GP is always required for these CPTs.

This modifier indicates that the service is part of a therapeutic treatment plan. Your documentation must include an established plan of care, showing progress and objective goals utilizing the reported services. Currently, Regence, Moda, Providence, UHC/UHSS, & VA/TriWest require GP on all PMR CPTs, which means the PMR documentation guidelines for GP must also be followed. Each carrier has their preferred way of submitting records, usually via their online portal; consult the carrier for details.

Modifier 59

Under the appropriate circumstances, modifier 59 is required on all PMR CPTs for all major carriers. However, applying modifier 59 indiscriminately can raise red flags with carriers. Your documentation must support the necessity of using the modifier.

This modifier indicates that the service is distinct and independent from other services performed on the same day, even if normally considered bundled. Documentation should explain the differences between the separate services and describe their role in the patient’s treatment plan. 

CPT 97140

IMPORTANT: Diagnoses for manual therapy cannot indicate “unspecified” areas (eg, M54.50, M25.519).

CPT code 97124 is not covered on the same visit as this code.

Documentation for services provided on the same day as any other therapies or manipulations must clearly show the manual therapy was provided to a different anatomical site than the region(s) that were treated.

CPT 97016

Should be reported no more than 1 unit per code per day per discipline; additional units will be denied.

Documentation must demonstrate the pain/inflammation/edema is significant, interferes with the patient’s functional abilities and fully meets the CPT descriptor. Include objective measurements of the area before and after treatment, type of device used, and show progress toward explicit functional goals using this therapy going back to Initial Encounter.

CPT 97124

CPT code 97140 is not covered on the same visit as this code.

Documentation must clearly support the need for continued massage beyond 6-8 visits, including any instruction, as appropriate, given to the patient and/or caregiver for continued treatment.