Don't Cheat Yourself!
Numbers — specifically, numbers used in coding — tell a story. And good “storytellers” — coders — get paid properly.
Those who do not know how to tell their stories correctly do not get paid fully and fairly. There are two reasons for this breakdown:
• Ignorance. Historically, doctors have not been trained adequately in business procedures. Because they lack a sound understanding of the coding process, many doctors fail to recognize billable treatment elements and thus overlook things that can and should be billed.
• Fear. The second reason for poor coding is fear. Doctors cheat themselves because they are afraid of denials, audits, paybacks, and even the fear of losing their license to practice. (Losing a license to practice almost never happens. On the few occasions it does, it is a severe penalty for a serious infraction.)
Projecting problems that may never occur, these doctors deliberately undercode to avoid risk and settle for less to avoid problems.
This fear spreads like a virus through the profession. Insurance companies know it and take advantage of it.
Both problems can be avoided simply by gaining a better understanding of codes and how to properly apply them. Ignorance can be overcome by education; fear can be defeated with information and confidence.
As you gain this understanding and awareness, it is important to recognize that codes cannot enumerate and codify every eventuality and you must use professional judgment, find the code that works best in the given situation, and apply it.
THE PROBLEM: THERAPEUTIC PROCEDURES
Practitioners usually do not have a problem coding modalities because the Food and Drug Administration (FDA) clearances provide easily understood guidance concerning what can be done with a given modality and how it can be used. Coding them is similarly precise.
Code 97014 (electrical stimulation), for example, clearly identifies what the code is for and both prescribes and limits when it can and should be used.
The gray areas have to do with therapeutic procedures — what doctors and therapists do with their hands — and the problem often begins with the first patient visit.
The procedures most often undercoded are 97110 (therapeutic exercises), 97140 (manual therapy), 97530 (therapeutic activities), and 97535 (activities for daily living).
Although these procedures are imprecisely defined, they are not difficult to justify. In fact, it is quite the opposite. All that is required is for you to identify in advance — either in the initial diagnosis or during subsequent outcome assessments — the conditions the codes are intended to treat.
As long as you do this, the door is open to major new income opportunities that rarely have to be defended.
If the codes are challenged, you have the evidence on hand to win an appeal.
Coding therapeutic procedures correctly relies on documenting your intent — that is, why you perform the treatment to achieve a result because of the symptoms the patient presents.
SOME EXAMPLES OF THERAPEUTIC CODES
Let’s look at some examples of therapeutic procedures, code by code:
• Code 97110 (therapeutic exercises). These are constant-attended exercises in which the intent is
to increase the patient’s range of motion, flexibility, strength, and/or endurance.
In rehabilitation scenarios, results are typically achieved by having the patient use such aids as elastic bands, exercise balls, treadmills, and recumbent bicycles, individually and in combination.
When to use this code: Code and bill for each activity administered intended to achieve a specific rehab goal.
This code is also appropriate for services to improve range of motion, flexibility, strength, and/or endurance in nonrehab situations.
• Code 97140 (manual therapy). Similar to procedures used in 97110, these procedures are intended to develop strength, endurance, range of motion, and flexibility. And, once again, they can represent opportunities frequently overlooked by doctors who do things during treatment that fall outside the adjustment process.
When to use this code:A doctor who is treating a trigger point may, for example, identify a related problem, such as a disk compression or muscle spasm. He may then apply manual traction to the patient’s calves to alleviate the compression, or use soft-tissue mobilization on the muscle spasm.
In such circumstances, the doctor can bill these and similar treatments within this code as long as the diagnosis supports the treatment.
• Code 97530 (therapeutic activities). This code refers to the use of dynamic activities to improve functional performance.
When to use this code: Essentially, this code is for treatments that can range in complexity from isometrics using elastic-band resistance, to stretching on an exercise ball, to a treatment on a flexion/distraction table.
When multiple parameters are assigned to the treatment, such as stimulating movement by isolating disk space while also generating a neuromuscular effect, the parallel intents can be coded and billed separately.
• Code 97535 (activities of daily living — ADL). This code is used to help patients accelerate recovery and alleviate pain.
When to use this code: Use this code when you discuss how to do icing, elevation, posture exercises, stretching, and similar activities with your patient. All of these activities fall under the ADL code. They are inherent to the treatment plan, and you can bill for them up to twice a month.
MEDICAL NECESSITY A MUST
Getting reimbursed for the codes you use depends upon intent. When codes have only a generic definition, it us up to you to find the code that best fits the service performed with regard to its appropriateness under the diagnosis.
The key to establishing medical necessity is accurate diagnosis. Make sure the initial exam clearly identifies the pain, functional abnormalities, and structural problems — what is wrong, why, and how long it will take to fix.
Then, code to fit — exercising judgment and understanding that one size does not fit all. When you understand the philosophy of codes, it’s easier to tell a convincing story.
Bharon Hoag is senior consultant in the ACOM Chiropractic Consulting Group (www.acomconsulting.com) and is certified as a professional coder by the American Academy of Professional Coders. He can be contacted at 866-286-5315, ext. 601 or by e-mail at firstname.lastname@example.org.