By Marty Kotlar, DC, CHCC, CBCS
Q: I own a spinal decompression therapy table. Most of my patients have insurance and want me to submit the claim to their carrier, but I am hesitant to do this. What is the most appropriate way to submit the claim?
A: Just about everyday this question gets asked and it’s a simple question, but there’s no simple answer.
“Just use the ‘traction’ code” was the common thought, but when the topic of insurance reimbursement and spinal decompression therapy was researched, it was found that the traction CPT code of 97012 is not acceptable by most Medicare carriers. Some Medicare carriers recommend CPT code 97799 and some require 97039.
Although Medicare does not consider certain spinal decompression therapies to be a payable service, some Medicare patients request or demand you bill for denial purposes. HCPCS code S9090 is another procedure code that some carriers may require for payment or to provide notification of patient financial liability.
If you collect cash from your patients for spinal decompression therapy, you should have two goals in mind from a coding and patient reimbursement aspect:
1. Try to get the insurance company to reimburse the patient directly, or
2. Try to get the insurance company EOB to state “patient responsibility.”
If you submit the wrong code, incorrect modifier, or do not have the patient sign the proper advanced notice of payment forms, you may have to return the money to the patient or insurance carrier.
EOBs that state “patient may not be billed for this service” or “patient not responsible” or “provider responsibility” are not ones you want to see. You work hard for your money and do not want a patient to ask you for a refund because of an insurance carrier EOB.
One action step to take is to call the carrier and ask what their position is on spinal decompression therapy. If you are “in-network,” you must follow their guidelines and they may have limitations on what financial responsibilities the patient has and how to submit the claims. Out-of-network providers may also have restrictions and may need to follow certain claim submission guidelines.
If the insurance carrier cannot provide the necessary information on the telephone, consider writing a letter requesting their policy on spinal decompression therapy.
Below is a sample letter to use as a
1234 Main Street
City, ST 12345
Re: Coverage for spinal decompression therapy
Dear Insurance Carrier:
I am requesting clarification for a procedure we have just begun to incorporate. This procedure is becoming widely regarded as one of the most-efficient ways and cost-effective approaches to treating herniated discs, spinal stenosis, disc degeneration, and sciatica. The procedure is nonsurgical spinal decompression therapy.
Spinal decompression therapy is used to create a distractive force to relieve pressure on the nerve roots. The device we use is called the __________________. Please see attached information regarding spinal decompression therapy from the equipment manufacturer and the numerous research articles that have proven the effectiveness of spinal decompression therapy.
I have reviewed my participating agreement with your plan (if in-network) and didn’t see any coverage information in the contract or fee schedule. I would like to know your coverage position on spinal decompression therapy and, specifically, what CPT or HCPCS code you require us to submit for performing this procedure.
Codes 97799 or S9090 seem most applicable for this service, but some carriers may prefer 97012, 97039, and 97139. What code do you suggest? Also, regardless of the code submitted, if you consider this a noncovered service, do we have to submit the claim for denial purposes and can we accept payment directly from the patient (if in-network)?
As a side note, our usual approach when a patient presents to this office with a herniated disc, spinal stenosis, disc degeneration, or sciatica is to begin care with traditional forms of therapy, such as ice/heat, electrical muscle stimulation, gentle chiropractic adjustments, exercise therapy, and soft-tissue mobilization. Only after a patient does not respond within a reasonable amount of time do we incorporate the use of spinal decompression therapy.
Please contact us with your response as soon as possible and let me know if any further information is needed.
Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, offers continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, firstname.lastname@example.org, or through www.TargetCoding.com.