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Physical Therapy Claim Denials & Reason Codes

by | Mar 10, 2022 | Medicare

Table of Contents:

Physical Therapy Claim Denials

Reason Code 59

While MPPR is not part of physical therapy claim denials, it is often mistakenly thought to be a claim denial by therapists and new billers.

The definition of MPPR is “Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017″

Insurance Reason Code 59 Multiple Procedure Reduction

This is not a denial or a penalty. Reason code 59 refers to the Multiple Procedure Payment Reduction MPPR). This reference to the Novitas-Solutions explanation helps explain what portion of the reimbursement is reduced by MPPR.

Full payment is made for the unit or procedure with the highest PE payment.

For subsequent units and procedures furnished to the same patient on the same day, full payment is made for work and malpractice and 50 percent payment is made for the PE for services submitted on either professional or institutional claims.

To determine which services receive the MPPR, we rank the services according to the applicable PE relative value units (RVU) and price the service with the highest PE RVU at 100% and apply the appropriate MPPR to the remaining services.

When the highest PE RVU applies to more than one of the identified services, we additionally sort and rank these services according to highest total fee schedule amount and price the service with the highest total fee schedule amount at 100% and apply the appropriate MPPR to the remaining services.

Solutions: Since this is not a denial, there is no recommended solution to eliminate this reduction.

MPPR explained in plain language:

Treatment example #1: Physical therapy treatment codes 97110 x2 units and 97140 x1 unit billed for date of service 01/01/2022.

Since 97110 is a higher relative value reimbursement the first unit of 97110 is paid at the full allowed amount rate, then the second unit of 97110 and the unit of 97140 is reduced by MPPR.

Treatment example #2: Occupational therapy treatment codes 97530 x2 units, 97110 x1 unit, 97535 x1 unit billed for date of service 01/02/2022.

Since treatment code 97530 is the highest relative value code provided, the first unit of 97530 is paid at the full allowed amount then the second unit of 97530, the unit of 97110 and 97535 are all reduced by MPPR.

Reason Code 119

Benefit maximum for this time period or occurrence has been reached.

Insurance Reason Code 119 Maximum Benefit

Solution: If the services continue to be medically necessary, reopen the claim within the MAC portal and add the KX modifier to the appropriate CPT Code line items.

If you do not know how to reopen a claim you may choose to search your MAC website for instructions.

After reopening the claim and adding the KX modifier the claim will reprocess and you will receive payment for the services delivered in excess of the financial threshold.

Anthony Maritato, PT

Anthony Maritato, PT

Private Practice Owner / Physical Therapist

After starting a private practice physical therapy clinic in 2022 with his wife Kathy Maritato, PT, Tony and Kathy grew their practice to five locations across two states.

Now, Tony and Kathy enjoy spending time treating patients in the morning, coaching therapists in the evening, and being home to play with their dog Tucker and 4 boys.

To learn move visit Anthony Maritato, PT

Table of Contents:

  1. Reason Code 59
  2. Reason Code 119