Neuromuscular reeducation can include movement, balance, coordination, kinesthetic sense, posture, and proprioception, but heed these coding tips
The proper reporting of neuromuscular reeducation (NMR) is one of the more significant coding dilemmas faced by chiropractors. One of the reasons for this is the many definitions of NMR that exist, and the even higher number of interpretations of these definitions.
Although NMR seems to have no universally accepted definition, it generally refers to a treatment technique or exercise performed by an individual with the purpose of improving, via the nervous system, the level of communication between the body and the brain. Also built into the NMR process of this phase is something referred to as proprioceptive training. Proprioception is defined as the sense of the relative position of neighboring parts of the body. The proprioceptive system provides feedback solely on the status of the body internally. It is the sense that indicates whether the body is moving with required effort, as well as where the various parts of the body are located in relation to each other.
There are excellent clinical indications for providing proprioceptive training by a chiropractor. But the more significant quandary to solve is how to report the work you’re doing, and whether that is by the code 97112.
Neuromuscular reeducation definitions
CPT® 97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception. Examples include Proprioceptive Neuromuscular Facilitation (PNF), Feldenkreis, Bobath, BAP’S Boards, and desensitization techniques. But let’s take a deeper look at the definitions of the words:
- Movement: an act of changing physical location or position or of having this changed;
- Balance: an even distribution of weight enabling someone or something to remain upright and steady;
- Coordination: the ability to use different parts of the body together smoothly and efficiently;
- Kinesthetic Sense: The ability to know accurately the positions and movements of one’s skeletal joints. Kinesthesis refers to sensory input that occurs within the body. Postural and movement information are communicated via sensory systems by tension and compression of muscles in the body — i.e., the kinesthetic sense is sometimes called “muscle memory,” and is the awareness of our own movement, for example when we walk, eat, write, or brush our teeth. The kinesthetic sense is based on proprioception, which is awareness of the position of our joints;
- Posture: the position in which someone holds their body when standing or sitting;
- Proprioception: perception or awareness of the position and movement of the body.
97112 should be able to be used for a relatively broad range of interventions and/or outcomes given the definitions above when provided and documented accordingly.
The challenges
Because the description of this code includes PNF stretching, it’s often billed in chiropractic offices for muscle work performed by the doctor or a massage therapist. The AMA has clarified that the description of the service is more specific.
From a CPT coding perspective, code 97112 is intended to identify therapeutic exercise designed to re-train a body part to perform some task that the body part was previously able to do. This will usually be in the form of some commonly performed task for that body part. Code 97112 is intended to identify neuromuscular reeducation designed to re-educate the muscle for some function it was previously able to do and not intended to identify massage to increase circulation, etc. For this reason, we strongly advise against using 97112 for muscle-related work within the confines of a chiropractic treatment plan. There are other codes better suited for describing this type of work.
Additionally, doctors who practice certain techniques may use a wobble chair or a vibration plate and describe this work as NMR and code it 97112. Because the majority of the time, patients are utilizing the wobble chair or vibration plate without direct one-on-one attendance, and without proper documentation of why these services are being provided, using code 97112 is problematic. From an insurance billing perspective, utilizing code 97112 requires a significant amount of medical necessity and the ability to meet the medical review policy definitions of the carrier for utilizing this code. For example, Aetna has a very specific medical review policy concerning the use of 97112:
Physical Therapy Services – Policy Number: 0325
Neuromuscular Reeducation — This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception to a person who has had muscle paralysis and is undergoing recovery or regeneration. Goal is to develop conscious control of individual muscles and awareness of position of extremities.
The procedure may be considered medically necessary for impairments which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity) that may result from disease or injury such as severe trauma to nervous system, cerebral vascular accident and systemic neurological disease. Standard treatment is 12-18 visits within a 4-6 week period.
Use careful evaluation
Because neuromuscular reeducation is such a confusing service to fit into a standard chiropractic treatment plan, we recommend that doctors carefully evaluate the use of the code.
Typical active rehab programs in chiropractic practices include the functional goal to improve the patient’s ability to do something they now lack the ability to do, but which they were able to do before. We have found that many of these services commonly performed in chiropractic offices would be more accurately described using code 97110©, therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. It relies greatly on the functional goals stated by the doctor and the components of the treatment plan to get the patient to maximum improvement. To use this service and code in your practice, make sure you clearly understand the medical necessity guidelines, any carrier’s medical review policy regarding the code, and your desired outcomes. Sleeping at night is much easier this way!
Kathy (KMC) Weidner is a Certified Medical Compliance Specialist (MCS-P), Certified Chiropractic Professional Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). 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 in the profession at KMC University and is known as one of the profession’s foremost experts on compliance, Medicare, documentation, and CA development.
