If you ask most chiropractors how confident they are in their coding practices, you will hear a variety of responses depending on how many services a doctor provides.
Even then, it can be a guess. This is a big problem, considering that how you are coding claims can make or break your compliance efforts.
In addition, if all the required elements of Evaluation & Management (E/M), Chiropractic Manipulative Treatment (CMT), therapies, and documentation are not met, it may raise a red flag for audits and result in the payer recouping funds from your office. Who needs that?
Let’s lay the foundation of how to be a confident coder.
What you really need to know
Knowledge is power! Whether you’re a doctor of chiropractic doing it on your own, a billing specialist, or even a certified coder, competently coding for chiropractic care requires being well-versed in these key areas:
- Health care terminology
- Anatomy and physiology
- Various types of CMT procedures per AMA standards
- Assessment of E/M services and E/M documentation guidelines
- Applying individual payer policy standards when making a coding decision
- Using daily notes and treatment plans to code for services and supplies provided
- Appropriate use of CPT, HCPCS, and ICD-10 codes
- Applying AMA and CMS rules for time-based services
- CMS bundling guidelines
- Appropriate use of modifier -59
- Coding diagnostic procedures
- And more….
There are three main elements to coding a claim: E/M, CMT, and ICD-10. First, take a moment to examine each element individually.
Evaluation & Management: E/M. These codes are among the most vital code sets used in the chiropractic profession. They represent the foundational initial visits, re-evaluation visits, and others that set the tone for episodes of care. When used appropriately, these codes demonstrate the level of evaluation and management provided to your patients and indicate how you should be reimbursed for providing that care. A clear understanding of how to bill for these services is crucial to receiving proper compensation for the care you provide.
The E/M codes most often used in a chiropractic office should be those belonging to the office visit series 9920X–9921X. They should accurately represent the level of history, examination, and clinical decision making required. It is critical that you determine the appropriate code level within this set to avoid inadvertently under- or over-coding, thereby risking non-compliance. And it doesn’t involve throwing a dart to decide— there are rules.
Chiropractic Manipulative Treatment: CMT. In a chiropractic office, the CMT code will likely be the most commonly billed service. Do not make the mistake of believing just because these codes are used daily, however, that they are somehow of less consequence. They are far more complex than many believe them to be, and lack of knowledge in this key area has contributed to an abundance of billing errors. Each CMT code contains a value for the amount of pre-assessment and post-assessment work, practice expense, malpractice value and others.
When billing CMT and E/M codes on the same visit, be aware that each CMT code has some level of E/M code embedded within it, as explained above. For this reason, it is not appropriate to charge an E/M service with a routine CMT visit. But there are a few exceptions when both may be appropriate:
- New patient visits
- New conditions
- Periodic examinations to evaluate whether a change in treatment plan is necessary
- Severe exacerbations
If any of the above listed exceptions are present, then it may be appropriate to charge both CMT and E/M codes for that visit, with the use of the -25 modifier (appended to the E/M) to indicate that a separate service was performed.
Many chiropractors feel that adjusting the full spine is much more beneficial and contributes to faster healing than simply treating the area of complaint. If any are in this category, remember that just because it may seem clinically appropriate to provide that level of service, it doesn’t mean that a third-party payer will recognize this it as being medically necessary. It is a best practice to be aware of the policy guidelines of each payer who you submit charges to, and only seek reimbursement for the areas deemed medically necessary by the payer.
International Classification of Diseases: ICD-10. The International Classification of Diseases, 10th Revision (ICD-10), is a set of codes used to describe patients’ conditions and diagnoses. ICD-10 is revised periodically to incorporate changes in the medical field.
Because your documentation should drive your ICD-10 code selection, there is no room to be vague in the selection of codes utilized. Using non-specified or unclassified codes repeatedly will eventually raise red flags for third-party payers, which can potentially have a negative effect on your reimbursement. Specificity is paramount, especially with ICD-10.
When it comes to coding ICD-10, a provider or coder should be able to confidently
- Understand how to use the tabular list in the ICD-10 code book.
- Select codes that appropriately reflect the patient’s condition.
- Describe the cause of the patient’s condition or mechanism of injury.
- Clearly convey a patient’s condition using “excludes notes.”
Some of the most valuable assets you can invest in for your practice are accurate and dependable coding resources. These are items are a must have for any chiropractic practice to be successful. Also, be certain to stay up to date as coding references are edited and updated annually.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P), a certified chiropractic professional coder (CCPC), and a Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been helping chiropractors improve the performance of their practices. She leads a team of 30 at KMC University and is a foremost expert on Medicare, documentation and CA development.
Nicki Brooks is a Certified Physician Practice Manager (CPPM) who entered the chiropractic field in 1999 as a Chiropractic Assistant. In the ensuing years, she held a variety of positions in the health care industry acquiring a diverse toolbox of skills. She joined KMC University in 2016.
Kathy or any of her team members can be reached at 855-832-6562 or info@KMCUniversity.com.