Does your documentation allow you to bill both a manipulative treatment and manual therapy with the 97140 CPT code?
I started working for the American Chiropractic Association (ACA) in June 1999 in the Professional Development Department, which had responsibility for coding. From my very first day, I fielded calls from members asking about the newfangled manual therapy 97140 CPT code that went into effect that prior January. Five codes were eliminated in favor of this new manual therapy code.
To say the change left confusion in its wake is an understatement.
The pesky early years of the 97140 code
One of the biggest challenges faced by doctors of chiropractic (DCs) was that the old code 97150-Myofascial Release, which many providers used for trigger-point therapy, was billed along with the CMT code for any muscle work performed in conjunction with the adjustment. However, with the CPT® update in 1999, more clarity began to emerge about what exactly was to be included with the adjustment and what wasn’t.
Many payers took the position at that time that 97140 was to be considered “mutually exclusive” with the CMT service in many circumstances. Providers were advised to use the 59 modifier when providing both CMT and 97140 to delineate that the services were separately identifiable. That was supposed to mean a separately identifiable area for the 97140 vs. the CMT service. That was not always the case.
Some providers performed both in the same anatomical region and billed with the 59 modifier anyway. Then, upon audit, it was revealed that the providers billed using the 59 modifier when the service was not performed in separate regions. Since so many providers were found to have “done it wrong,” a knee-jerk reaction ensued when some payers never covered both CMT and 97140 on the same visit. Only upon appeal, with clear documentation of the separately identifiable regions, would the 97140 CPT code service be paid.
The pesky 97140 CPT Code: 2021
Some payers, such as Optum, have finally taken the guesswork out of when and how to append the -59 modifier when performing CMT along with procedure code 97140 – manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction) on one or more regions (15 minutes each).
This, coupled with providers beginning to better understand when both services are billable on the same visit, has loosened the noose we felt as a profession in previous years. But, as more clarification has come forth, some providers are still stuck in the past and unaware of the rules they are expected to follow when billing both. Some, like Optum, have clarified their policy for when both services are billable and payable.
We have a member who deals with Optum as the payer for Veterans Affairs (VA) patients, and who is dealing with this situation now. They hadn’t kept up with the rules, and were billing both services at the same time, incorrectly. So far, almost $20,000 has been recouped from the provider due to the billing errors. Let’s make sure you don’t find yourself in a similar situation.
A summary of Optum’s policy on CMT/97140
“Manipulation and Manual Therapy CPT® code 97140 (Manual therapy techniques) may be billed on the same date of service as a CMT code when the manual therapy service is provided to a different, noncontiguous body region than the CMT…CMS has established the following four HCPCS modifiers (referred to collectively as –X{EPSU} modifiers) to define specific subsets of the -59 modifier: XE Separate Encounter; XS Separate Structure; XP Separate Practitioner; XU Unusual Non-Overlapping Service…The National Correct Coding Initiative (NCCI) Edits – developed by the CMS – provides guidance in the application of modifier – 59. Different diagnoses are not adequate criteria for use of modifier -59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed on different anatomic sites or during separate patient encounters…. From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, the treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. [NCCI, 2017]”
This means that you can append either the -59 modifier or the X modifiers; both are accepted forms of billing at this time. But what about the reference to noncontiguous body region? For us to understand Optum’s interpretation of body regions we should start with what is considered a “region” when reporting CMT. The policy says:
“For the purposes of reporting CMT codes, there are five spinal regions and five extraspinal regions. The spinal regions are: cervical (includes the atlantooccipital joint); thoracic (includes costotransverse and costovertebral joints); lumbar, sacral; and pelvic (sacroiliac joint). The extraspinal regions are: head (including the temporomandibular joint, but excluding the atlantooccipital joint); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen.”
Notice how Optum pulls it all together. Optum clarifies contiguous and non-contiguous body regions as follows:
“The treatment of myofascial structures using manual therapy techniques in the same organ (spine), where CMT was performed and was contiguous (cervical and thoracic), does not constitute treatment of different anatomic sites.
The treatment of myofascial structures using manual therapy techniques in the same organ (spine), where CMT was performed and was not contiguous (cervical and lumbar), does constitute treatment of different anatomic sites.
The treatment of the cervical spine and a shoulder joint does constitute treatment of different anatomic sites.”
Compliance with billing/documentation rules
Optum, like most payers, publishes their Medical Review Policy (MRP) for such things and providers who bill the payer should take heed of the rules of the game. These are important factors to review before billing these services, ensuring that the clinical record clearly matches the CPT® codes billed:
- Manipulation was not performed to the same anatomic region or a contiguous anatomic region (e.g., cervical and thoracic regions were contiguous; cervical and pelvic regions were noncontiguous)
- The clinical rationale for a separate and identifiable service must be documented (e.g., contraindication to CMT is present)
- Description of the manual therapy technique(s) location (e.g., spinal region(s), shoulder, thigh, etc.)
- Time (e.g., number of minutes spent performing the services associated with this procedure) meets the timed-therapy services requirement
- The 97140 CPT code is appended with the modifier -59 or the appropriate -X modifier
If you are billing 98941 along with 97140, you may find it very difficult to meet all of the criteria listed above. In addition to documentation, be sure your billing is consistent with the reason given for performing 97140 by pointing to the correct diagnosis code. The reason (diagnosis/condition) for performing CMT should never be the same as 97140 when billing. See a proper billing example below:
How would you answer these questions?
Considering the increasing scrutiny and number of audits, it’s time for a self-check to make sure you have what’s necessary to properly bill both CMT and 97140 on the same visit:
- Is the manual therapy performed as a pre-cursor to the adjustment in the same or a contiguous body region? If so, you shouldn’t charge for both.
- Is the manual therapy performed in a separate, non-contiguous body region? If so, make sure you clarify separate diagnoses, document both conditions, and include both services in your treatment plan at the beginning of the episode of care.
- Do you use diagnosis pointers when listing the procedure 97140 CPT code? If so, are they pointing to the same diagnosis as the CMT?
If you routinely perform both CMT and 97140, make sure you pay attention to the coding guidelines provided by the payers with whom you deal. Look for MRP that outlines their rules for billing both services at a time and what they expect to be present in the documentation.
KATHY WEIDNER, better known professionally as Kathy Mills Chang, is a certified medical compliance specialist (MCS-P) and a certified chiropractic professional coder. Since 1983 she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. She leads the largest team of certified specialists under one roof in the profession, at KMC University, and is known as one of the profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM-KMC or info@KMCUniversity.com.
