17 dos and don’ts of coding and compliance
By Marty Kotlar, DC, CHCC, CBCS
I have been billing and coding the same way since I opened my office seven years ago. Can you provide some general guidelines so I can be sure I am billing properly and coding compliantly?
Since changes occur to CPT codes and ICD-9 (diagnosis) codes every year, you are making a wise decision learning as much as possible about CPT coding.
Here is a list of the most common CPT coding and compliance dos and don’ts:
1. Do not bill 98941 (spinal, 1-2 regions) or 98942 (spinal, 3-4 regions) on every patient for every visit — unless you can absolutely, with 100 percent accuracy, prove medical necessity in your notes.
2. Incorporate re-evaluations. Keep the doctor and insurance company (and the patient) aware of the patient’s progress.
3. Create a written treatment plan for every new patient.
4. Do not routinely waive co-pays, deductibles, and co-insurance.
5. Do not tell the patient you will accept the co-pay amount listed on their insurance card if you are out-of-network. This may cause the patient to assume you are an in-network provider.
6. Do not use “active” therapy codes for spinal decompression therapy, low level laser therapy, or dry hydro-therapy devices.
7. Only bill insurance companies for medically necessary visits. Do not automatically bill for the amount of visits they cover. For example: Just because an insurance carrier may pay for 20 visits, do not bill for all 20 visits.
8. Know how and when to code and bill for group therapy (CPT code 97150) vs. individual therapy.
9. Do not bill for time-based codes if the procedure only takes one to two minutes to perform.
10. Do not bill 97140 (manual therapy) if you’re really doing a 98940 procedure (spinal, 1-2 regions).
11. Do not routinely take full-spine x-rays on every new patient.
12. Make sure your new patient-intake questionnaires are properly completed and make sense. For example: If the intake questionnaire only relates to one region of the spine, it is not possible to bill 98941 (spinal, 3-4 regions) or 98942 (spinal, 5 regions).
13. Do not bill for a report of findings. If you choose to bill for counseling/coordination of care, make sure you can substantiate it in your documentation.
14. Re-evaluate your CPT/ICD-9 codes every month or whenever clinically necessary.
15. Do not bill new-patient codes unless the patient has not seen you for three years.
16. Do not bill Medicare using the AT modifier for maintenance care.
17. Use caution when billing modifiers 25 and 59. (Modifier-25 indicates a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Modifier-59 identifies procedures/services that are not normally reported together, but are appropriate under the circumstances.) Two HHS Office of Inspector General reports stated that each modifier was used incorrectly nearly 40 percent of the time.
Modifiers 25 and 59 are used to alert the payer that a second service should be paid separately, due to special circumstances.
Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, Inc., is offering continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, at firstname.lastname@example.org, or through the Web site www.TargetCoding.com.