Modalities, coding selection and carrier policies for spine decompression therapy
A modality is defined as “Any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical or electrical energy.” By contrast, a procedure is defined as “A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Physician or therapist required to have direct (one-on-one) patient contact.” The significance of this distinction is that for modalities such as spine decompression therapy, the physical agent (and level of contact required) defines the code — not the therapeutic result achieved.
Utilizing the physical agent
Without question, traction or spine decompression therapy utilizes the physical agent of mechanically created traction forces that are applied to produce a biologic change in the tissues. There is no application of clinical skill necessary during the delivery of the therapy that requires direct one-on-one contact such that the service could ever be classified as either a constant-attendance modality or as a procedure.
The cognitive aspect of the service occurs prior to the service and is necessary to determine settings relating to how the device will function (i.e., how much pull, how long, angle of pull, etc.) similar to electric stimulation or any other modality.
Having substantiated that decompression therapy is a modality, the only remaining issue is whether it is a supervised or constant-attendance modality. Supervised modalities are defined as: “The application of a modality that does not require direct one-on-one patient contact by the provider.” For comparison, “constant-attendance” modalities are defined as: “The application of a modality that requires direct (one-on-one) patient contact by the provider.”
It should be noted that the definitional requirement for direct “one-on-one” contact is somewhat of a misnomer given that in a separate clarification, both the AMA and CMS indicate that constant attendance can be provided to more than one patient at a time. Truly direct one-on-one contact procedures cannot be provided to more than one patient at a time. As a result, it is best to take a literal definition of constant attendance (i.e., the provider or therapist must be in constant attendance with the patient and that such attendance is necessary for effective or safe delivery of the therapy).
It has not been established that decompression therapy “requires” constant attendance or direct one-on-one contact during delivery of the therapy (hence it is supervised) and the therapeutic result is delivered completely by the physical agent produced by the device itself (hence it is a modality). In support of the assertion that only supervision is required, we find that decompression therapy can be safely performed without constant attendance. Some manufacturers have supported this in their 510(k) submissions on the basis that should a problem or adverse reaction develop suddenly, the patient can terminate the therapy.
As a result, constant attendance is not necessary, and the service is properly classified as a supervised modality. Having arrived at this conclusion, we look to the enumerated supervised modality codes and find CPT 97012, which is defined as follows: “Application of a Modality to One or More Areas; Traction, Mechanical.” This exactly describes the physical agent supplied by every “decompression” table given that for patients with a disc condition, mechanical traction forces are applied to produce the decompression effect. CPT 97012 is therefore the appropriate code.
Despite this, carriers have taken advantage of manufacturers’ arguments that “decompression” is not or is a different type of mechanical traction — if for no other reason than it permits them to create a distinction without a difference and therefore deny coverage. Some carriers specifically state that participating providers should code “decompression” therapy using S9090 instead of 97012 to ensure that, if billed by the provider or patient, the service is denied. As a result, a misunderstanding of this simple coding principle has resulted in what is arguably a great therapy that few if any carriers will knowingly pay for.
Spine decompression therapy and coding selection
From a coding perspective, one must recognize that decompression is the therapeutic result of a specific form of traction — nothing more. As noted above, where modalities are concerned, the therapeutic result is irrelevant (if it was, we would need dozens of codes for electrical stimulation alone). Only the physical agent being applied (and the level of contact required) is relevant to modality code selection. CPT 97012 is the correct code for mechanically delivered traction regardless of whether it causes decompression or not.
For medicine, traction is defined in Webster’s Dictionary as follows: “1. a. The act of drawing or pulling, especially the drawing of a vehicle or load over a surface by motor power. b. The condition of being drawn or pulled. 2. Pulling power, as of a draft animal or engine. 3. Adhesive friction, as of a wheel on a track or a tire on a road. 4. Medicine. A sustained pull applied mechanically especially to the arm, leg, or neck so as to correct fractured or dislocated bones, overcome muscle spasms, or relieve pressure.”
As such, even for purposes of coding, traction is simply applying a mechanically induced pulling force. The outcome of such a force is not germane to the definition of traction either generally or in the specific circumstance of modality code selection in CPT. Unfortunately, manufacturers of “decompression” traction devices attempted to justify a different code on the basis that decompression was a better or a different type of traction, with the ultimate assumed purpose of obtaining better reimbursement for this form of traction.
While successful in establishing that “decompression” therapy is different as evidenced by the creation of the HCPCS Level II code S9090, manufacturers and providers failed to anticipate that by creating such a difference, the door has been opened to allow carriers to deny coverage for this form of traction. Carriers have taken advantage of the opportunity to deny decompression traction while continuing to pay for traditional forms of traction and have supported the decision to deny this “new” form of traction, claiming that spine decompression therapy is not proven and is experimental.
We must also understand, contrary to the inferences in most payer policies, that the specific traction table used does not make the traction “decompression” per se. Instead, the condition requiring traction and the intended therapeutic result to be achieved defines whether the traction is “decompression” or not. Commonly marketed “decompression” tables can be utilized to perform simple axial traction for conditions other than disc problems where decompression of the disc is intended. Where used in this manner, the traction is not “decompression” as defined in many payer medical policies; however, most policies do focus on the table used rather than the diagnosis of the patient and/or the intended outcome of the therapy.
Carrier policies and the history of traction
Ultimately, we must recognize that current carrier policies were most likely motivated by negative experiences. There are a plethora of cases where exorbitantly-high fees were charged (I have seen as much as $3,000 per treatment for the traction service alone), or what carriers have perceived as abusive coding practices (see above). As a result, reversal of the current situation of non-coverage is not likely, but if it occurs, it will likely require all of the following:
- Carriers will need some time to get over their prior bad experiences relating to how this service has been billed in the past such that they might be receptive to considering changing their policies.
- The S9090 code must be eliminated, thereby putting an end to a code difference in the forms of traction. To deny one, carriers would have to deny all forms of traction. Since traction is and has been widely used, and is generally covered under most insurance plans, this is not likely, but some carriers have gone this route.
- Additional peer reviews and unbiased clinical trials will have to be provided that support the effectiveness of this form of traction and its cost-effectiveness. Additionally, such research should provide guidance for the analysis and identification of conditions that require decompression traction and should additionally define clinically appropriate protocols for the proper application of this therapy.
- Providers must be willing to accept the reimbursement allowance offered by CPT 97012. This may be the major sticking point as it is presently more advantageous (financially) for spine decompression therapy providers to charge patients directly for this service on the basis that the service is not covered.
Decompression and reimbursement
Restrictions on the number of modalities that can be performed and decreasing allowances for any form of traction make it impossible to perform covered forms of traction profitably. Therefore, as a non- covered service, providers are free to provide “decompression” forms of traction for cash at reasonable, but profitable fees.
Part I of this article appeared in the previous 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 and 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.