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Confused by the Maze of Billing and Coding Rules?
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By Marty Kotlar, DC

Author's Note: If you work with insurance companies, chances are pretty good that you and your staff often have billing and coding questions. This column seeks to answer some of the most commonly asked questions, for both traditionally structured chiropractic practices and multi-discipline practices.

The first two questions relate to physical medicine and rehabilitation procedures such as therapeutic ultrasound (97035), therapeutic exercise (97110) and manual therapy techniques (97140). These procedures have 15-minute time values attached to them.

Question: What procedure code or modifier would be used if the service lasted only seven to 10 minutes?

Answer: When reporting physical medicine and rehabilitation codes, which require that 15 minutes be spent in the application of the modality (e.g., 97035, 97110, 97140), those 15 minutes must be spent in pre-, intra- and post-service work. If less than a total of 15 minutes was spent, the CPT code describing the modality would be reported with the modifier 52 (reduced service).

Question: If the service lasts 22-25 minutes, can we code for two units in box 24G of the HCFA claim form?

Answer: If a physical medicine modality is applied or a therapeutic procedure performed for longer than the minutes specified in the code descriptor, it would be appropriate to report the CPT code twice. In the example given, total time spent was 22-25 minutes. The code would be reported as listed in the CPT for the first 15 minutes; then the code would be reported again, appending the 52 modifier to indicate the remaining time was less than the 15 minutes specified in the code descriptor.

The remaining questions relate to a multi-discipline office environment. In these examples, a physiatrist (Dr. P) and a chiropractor (Dr. C) practice together in one office. The physiatrist examines a new patient and decides the patient should receive a chiropractic evaluation.

Question: For Dr. C, do we use a consultation code (99243), a new patient code (99203) or an established patient code (99213)?

Answer: If Dr. P requests an opinion or advice from Dr. C, the chiropractor may report a consultation code (such as 99243, if key components meet this level of consult service) for the E/M service provided. If Dr. P is not asking for an opinion or advice, but instead is transferring care of the patient to Dr. C, an appropriate level of a new patient E/M service may be used.

In addition, the use of new versus established patient codes depends on whether doctors in the same practice and specialty have provided professional services for the patient within the past three years. If professional services have been provided within three years, established patient codes should be used to identify the services provided. If not, new patient codes should be used. Therefore, if Dr. C, or any other chiropractor in the same group, has provided professional services for the patient within the past three years, the code 99213 should be used to identify the E/M outpatient service provided.

Question: For Dr. C, can a chiropractic diagnostic test be performed and charged on the same day as the evaluation?

Answer: The E/M service may be separately identified using a code appropriate for the level of service provided if the service is: significant (i.e., a service that has components that warrant identification with some level of E/M) and separately identifiable (i.e., a service that contains components performed separately from, or not included as part of some other service). In addition, the 25 modifier is appended to identify the E/M service as a significant, separately identifiable service provided on the same day as the testing procedure.

Question: If the patient goes back to Dr. C on another day to receive the results (level-two evaluation) of the test, does Dr. C use the code 99242 or 99212?

Answer: If a patient goes back to Dr. C for results (meeting key component requirements for a level-two visit), the code 99212 should be used to identify the service provided. s

Dr. Kotlar, is the senior billing and coding consultant for Integrated Holistic Solutions, Inc., a national consulting firm for holistic healthcare professionals who practice in a multi-discipline environment. He lectures extensively throughout the United States to numerous multi-discipline practices. Dr. Kotlar can be reached at 800-227-9269; fax: 914-428-4060; e-mail:

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