April 2002

Coding: Information Is Power
When It Comes to Getting Paid
By Anthony W. Hamm, DC, FACO

As we ply our trade as chiropractors, our primary cognitive function is clinical decision-making. This, of course, involves taking a history, performing a diagnostic evaluation, formulating a diagnostic impression and finally, developing a therapeutic plan. The end-product of these activities is ideally a satisfied patient and a profit for our efforts. This is where correct coding enters the equation.

All chiropractic practices (with the possible exception of strict cash-only practices) must report services rendered to third-party payors. These include indemnity insurance companies, managed-care organizations (MCOs), workers’ compensation boards, automobile insurance carriers, and state and federal agencies such as Medicare and Medicaid.

Procedures that are normally performed in chiropractic offices include, but are not limited to, evaluation and management services, chiropractic manipulative therapy, including extra-spinal manipulation, radiology, and physical medicine services (including rehabilitation).

“Physicians’ Current Procedural Terminology, Fourth Edition” (CPT), copyright 2001 by the American Medical Association (AMA), is the most widely accepted nomenclature for reporting health-care services and procedures. “CPT” is a registered trademark of the AMA.

The chief purpose of CPT is to provide uniform language that will accurately describe health-care services. CPT is a work-in-progress with yearly revisions by the CPT Editorial Panel, with the assistance and input of providers representing various areas of healthcare, including chiropractic. Our profession is represented on the AMA Health Care Professionals Advisory Committee (HCPAC) by Dr. Craig Little. Dr. Jerilynn Kaibel has represented chiropractic on the AMA Relative-Value Update Committee (AMA RUC).

As a direct result of this representation, chiropractic has maintained an effective voice in the ongoing CPT process, including the advent of chiropractic manipulative treatment (CMT) codes 98940, 98941, 98942, and 98943.

The American Chiropractic Association (ACA), through its Coding and Reimbursement Committee, reviews existing CPT nomenclature, current CPT changes, existing Resource-Based Relative Value Scale (RBRVS) work and practice expense values, and general coding trends. The primary goal of the ACA recommendations is to help provide practicing doctors of chiropractic with the most accurate method of reporting the true level of service they perform, including physician-level services.

As a result of varied interpretation of codes by different carriers, correct coding remains enigmatic. Nevertheless, it is the responsibility of providers to code their services correctly. The Centers for Medicare and Medicaid Services (CMS, formerly HCFA) uses coding edits that are designed to electronically detect code pairs reported to Medicare that are not normally used together.

The National Correct Coding Initiative (CCI) was formed in order to oversee this process. CCI edits basically red-flag inappropriately paired codes that are reported to Medicare. These edits also apply to code pairs without the use of proper modifiers.
There are two types of CCI edits: “mutually exclusive” and “comprehensive and component.” Mutually exclusive edits involve the use of codes that cannot reasonably be performed during the same session. An example of this would be billing chiropractic manipulative therapy (98941) and osteopathic manipulative therapy (98926) on the same visit. Comprehensive and component edits are code pairs wherein the comprehensive code includes certain services that may be included as a component in other codes in the same family.

It should be understood that CCI edits were created solely for use by Medicare. As we are painfully aware, the only covered service paid to doctors of chiropractic under Medicare is manual manipulation of the spine to correct a subluxation. Therefore, CCI edits frequently deny other codes as being “comprehensive and component” (also termed as “bundled”) with CMT codes.

The most widely problematic code pairs edited by CMS/CCI occur when reporting CMT codes (98940-98942) and certain physical medicine codes on the same visit. These include manual therapy techniques (97140), therapeutic exercise (97110), and massage therapy (97124). According to CPT, 97110 and 97124 may be utilized on the same visit as CMT. Code 97140 may also be reported on the same visit, provided the manual therapy is applied to a separate body region (for example, lumbo-sacral CMT and mobilization of the shoulder of a patient with multiple injuries). Of course, as with all coding and billing issues, proper documentation and clinical justification must be evident.

Problems occur when these denials are forwarded to a secondary carrier that may cover services other than spinal CMT, or when CCI edits are independently purchased and utilized by other payors who then deny otherwise contractually covered services. The ACA has been in dialog with CMS to try to correct these shortcomings in the current edit system; the association is also working to educate private vendors who try to use CCI edits to inappropriately deny valid claims.

Questions about coding commonly involve the proper use of evaluation and management services (E/M services). Actually, E/M coding is a fairly straightforward and uncomplicated proposition. CPT codes 99201-99205 are new patient evaluation and management codes. These codes describe patient encounters beginning with a problem-focused history, problem-focused examination, and straightforward medical decision-making (99201), and ending with a comprehensive history, a comprehensive examination, and medical decision-making of high complexity (99205).

CPT codes 99211-99215 are similarly described and utilized for established patients. As a general rule, a new patient is defined as someone who is new to your practice or a patient who has not been seen in three years or longer.
Under the proper circumstances, it is appropriate to report CMT codes with evaluation and management codes.

According to the AMA’s “Physicians’ Current Procedural Terminology, Fourth Edition”:
“The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional Evaluation and Management Services may be reported separately using modifier -25, if the patient’s condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. The E/M service may be caused or prompted by the same symptoms or condition for which the CMT service was provided. As such, different diagnoses are not required for the reporting of the CMT and E/M service on the same date.”

For example, should a patient present with an exacerbation or aggravation of a problem and it is clinically appropriate to further examine the patient in order to properly manage the condition, reporting both the CMT and E/M service on the same date is allowed.

The creation of CPT codes is a dynamic and ever-evolving process. The ACA, through its Coding and Reimbursement Committee and staff, remains poised to provide necessary clarification for the chiropractic profession.

The “ACA’s Official Chiropractic Coding Solutions 2002” is a guide published by the American Chiropractic Association to provide doctors and their staff with valuable, up-to-date answers to their coding/ reimbursement questions. Beginning with this edition, doctors who purchase the reference can also purchase quarterly coding updates, published in conjunction with Chiropractic Economics.

Dr. Hamm has been in practice in Goldsboro, N.C., since 1980. He is a 1979 graduate of National College of Chiropractic and is a Diplomate of the American Board of Chiropractic Orthopedists. He is the American Chiropractic Association (ACA) delegate representing North Carolina and chair of the ACA Coding and Reimbursement Committee. Specific questions about coding should be routed through the ACA at 800-986-4636.