Manufacturers vs. the CPT Editorial Panel vs. the Department of Health and Human Services in the coding of chiropractic decompression therapy
With the rather prolific nature of post-payment audits by commercial insurance payers, chiropractic physicians are moving to cash practices at an enthusiastic rate – and in the process, realizing improved long-term profitability and renewed enjoyment in their professional lives. Beyond provision of traditional chiropractic care, practices making this move commonly incorporate other cash services to further improve profitability and market reach. One such service is chiropractic decompression therapy, which has long been considered (fortunately) a non-covered “experimental/investigational” service by third-party insurance payers.
Chiropractic decompression therapy and coding
“Decompression therapy” is a “term of art” that was created by early device manufacturers as a way of explaining an alleged unique therapeutic result of certain traction devices while also attempting to justify an alternative means of coding for this type of traction.
These manufacturers, desirous of selling traction equipment at prices in excess of $100,000, needed to find a way of avoiding the use of CPT 97012 and its relatively low reimbursement rate in order to convince potential purchasers that substantial investment necessary to purchase their equipment would be cost justified. The reimbursement for CPT 97012 averaged approximately $6-25 depending on the payer. At these reimbursement rates, it was impossible to justify the purchase of a device with a six-figure price tag.
As a result, manufacturers initially lobbied for a decompression-specific CPT code as a means of getting better reimbursement on the basis that “decompression” traction was a different form of traction than that provided by existing traction tables. The CPT Editorial Panel denied their request given that an existing modality code accurately defined the physical agent employed by these “decompression” traction tables. Ultimately, the Department of Health and Human Services (HHS) issued a temporary national Healthcare Common Procedure Code (HCPCS) – S9090 (vertebral axial decompression, per session) to describe this particular form of traction.
Unfortunately, as a private payer code, the “S” codes (including S9090) are invalid for Medicare. This has implications in workers compensation or personal injury cases where the state cost containment rules mandate use of codes acceptable to Medicare. In the commercial insurance arena, no carrier to my knowledge (except possibly in an employer self-funded plan) pays for this code in specific or for “decompression therapy” in general. The perplexing issue is that most all carriers pay for mechanical traction.
‘Sounds like’ coding
Because S9090 is generally not covered and the reimbursement for CPT 97012 is considered by those performing this service to be deficient, some have turned to a variety of other “sounds like” coding options that were recommended by either manufacturers or consultants for chiropractic decompression therapy.
Codes that have been utilized include nerve decompression (CPT 64722 — Decompression; unspecified nerve(s) (specify) which is a major “open” surgical procedure with a 90-day follow-up period), or therapeutic activities (CPT 97530 — Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes). These as well as other less-utilized coding alternatives are ultimately wrong. Where used, carriers consider that the use of such codes to obtain or increase the amount of payment is an improper misrepresentation of the service provided that misled the carrier into making payments that likely would not have been made had they understood what service was actually rendered.
A number of providers who have used these coding alternatives have been targeted in civil and/or criminal false claims actions. Having been involved as an expert in several of these cases, I have had an opportunity to evaluate this issue in detail from both sides.
Both sides of the issue
First and foremost, decompression traction devices are all classified by the FDA as motorized traction devices. Some manufacturers have made the additional assertion that their device causes “decompression” of an intervertebral disc to occur as part of their pre-market approval submissions.
While the FDA has not classified these devices as “decompression” devices, they have permitted them to be marketed as such for chiropractic decompression therapy. Manufacturers have consistently argued that decompression traction is somehow different than traditional forms of traction. While this may be so on the basis of how the traction force is applied and the therapeutic result that such differences create, by taking this position, what most manufacturers have forgotten to consider is that regardless of whether “decompression” traction is better or produces a different therapeutic result than other forms of either axial or “inter-segmental” traction, the therapy is and will always be traction fundamentally.
Despite the differences, CPT classifies modalities based on the physical agent and the level of contact required during delivery of the service. It does not differentiate modalities based on the therapeutic result obtained. Traction is clearly a supervised therapeutic modality and the result obtained is irrelevant. To understand the significance of how modality codes are selected, it is important to consider what a physical medicine modality is and how it differs from a procedure.
Part II of this article will appear in the next issue of Chiropractic Economics.
MICHAEL D. MISCOE, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA, CEMA, AAPC Fellow, has a bachelor of science degree in electrical engineering from the United States Military Academy, has a juris doctorate degree from Concord Law School, and is a Certified Professional Coder, Certified Ambulatory Surgical Coder, Certified Urology Coder, Certified Chiropractic Professional Coder, Certified Professional Compliance Officer, Certified Professional Medical Auditor, Certified Evaluation and Management Service Auditor, AAPC Fellow, the president of Practice Masters Inc., and the founding partner of Miscoe Health Law LLC. He has nearly 30 years of experience in the health care industry and over 25 years as a forensic coding/compliance expert and consultant. He has provided forensic analysis and testimony as an expert witness on a wide range of coding and compliance issues in civil and criminal cases on behalf of providers and payers. His law practice concentrates on representation of health care providers involved in post-payment disputes with commercial and government payers. Learn more at codingexperts.com.
