How detailed documentation fixes calamitous chiropractic coding and billing

Here are the most common coding missteps and ways to eliminate your non-compliance issues with chiropractic coding and billing

The CPT® descriptive terminology and associated code numbers provide the most widely accepted nomenclature used to report procedures and services for processing claims, conducting research, evaluating health care utilization, and developing medical guidelines and other forms of health care documentation. The sequence of selecting a code to describe the work performed is always that the code is chosen based on the documentation for chiropractic coding and billing.

If the documentation reflects two spinal regions adjusted, and CPT® code 98941, describing 3-4 spinal regions is selected, that’s an error … and a compliance issue. But who really looks at this anyway? The documentation is usually not submitted with the billing.

Standardized documentation and coding guidelines

It would be wonderful if there were a magic button to press to know exactly what documentation guidelines to follow to perform self-audits and evaluate your compliance with chiropractic coding and billing. Unfortunately, this isn’t so.

Documentation standards are often open to interpretation, whether from a licensing board, a payer or a malpractice attorney. For this reason, it’s important to set policies and procedures for the documentation and coding standards in your practice using reliable resources.

Resource Guideline Purpose/Content
Your State Licensing Board If your state has specific documentation guidelines, they should be listed in your state rules — usually available to you on your board’s website. If your state has a requirement to obtain informed consent, it’s usually listed there.
National Organizations The American Chiropractic Association published Clinical (Medical) Documentation Recommendations. Its intention is that it can be used as guidance when formulating documentation standards. The American Medical Association (AMA) publishes guidance regarding documentation and coding through the AMA/CPT process.
Malpractice Documentation Guidelines Your malpractice carriers may have recommendations for policyholders. These are usually listed on their websites. Pay particular attention to their recommendations for obtaining informed consent.
Third-Party Payers If you’re billing payers and expecting them to pay toward a patient’s financial responsibility in your office, they set the rules. Medical review policy particular to the service being rendered can often be found on the payer’s website. Chiropractic medical review policy often includes the minimum standards for documenting the medical necessity of the service as well as the necessary components to include in the patient’s health record.
Centers for Medicare and Medicaid Services (CMS) Documentation guidelines are published for evaluation and management (E/M) services. Look to these guidelines for all E/M documentation guidance, even for commercial payers. Additionally, each Medicare administrative contract (MAC) publishes local coverage determinations (LCD) and/or coding and billing articles that outline guidelines for initial and routine visits for Medicare patients.

In the absence of other state or local guidance, in my opinion, using the Medicare standards for documentation and coding is simple and thorough. Since Medicare’s documentation standards are clear and easy to follow, they make an excellent guideline for all the practice’s documentation.

Often, more minimum documentation standards can be met for non-third-party patients or those on maintenance care. This is where an understanding of what your board expects is critical. Regardless of the more robust requirements often associated with third-party payers, your minimum requirements as noted above should always be considered with chiropractic coding and billing.

When billing any third-party payer, be familiar with their medical review policy (MRP). They are usually found within the medical policy section of the carrier’s website, but are often made available to clinics through a provider portal. Look for terms such as Clinical Coverage Bulletin, Provider Tools, Reimbursement Policy, and Medical Review Policy and Treatment Guidelines.

Know your contract and provider manual

Most payers provide a provider manual, either physical or electronic, once the provider is credentialed. Updates are usually carried out electronically. This can be in the form of a monthly newsletter.

Be sure you are subscribed to all electronic media from the payers you deal with. It’s each provider’s obligation to stay on top of provider news and updates regarding the contract agreement as a network provider. Make sure you know where to access this information online for all current payers.

We suggest that you subscribe to all payer correspondence with a practice email that won’t change. For example, subscribe under [email protected] or [email protected] so that those email addresses can be redirected to whoever is responsible for such updates. That way, if one person leaves the practice, the email is redirected to the new person. Never subscribe under a CA’s email address.

As you collect these payer documents for each carrier (whether you print them or digitally bookmark them), house the documents somewhere that can be accessed quickly should a question arise about sending in a claim for care or to determine who is financially responsible for specific care.

Chiropractic coding and billing: follow standard guidelines

It’s interesting that all payers don’t evaluate coding the same way. Some have more stringent rules for what is deemed medically necessary, while others consider similar services to be experimental, investigational and unproven.

One recent example is demonstrated with coding the roller table traction as mechanical traction, 97012.  Roller table type traction has been around for decades, and patients love it. Variations on roller table traction include full massage chairs that can lay flat and stretch the patient, as well as hydro-bed massagers. These massagers use water as the force to create the muscle relaxation and the desired effect. For years, the American Chiropractic Association’s position statement validated roller table type traction as “auto-traction,” which is the use of the body’s own weight for tractioning.

Recently, more third-party payers have written medical review policy deeming roller table type traction as experimental, investigational and unproven. However, because it is usually billed as 97012, traction, the payer wouldn’t know that the service performed was roller table and would likely pay it. It’s up to the provider to be aware of these kinds of rules. Billing with a deceiving code could be dangerous. In July 2020, the AMA’s CPT Assistant published a clarification that seems to refute the notion that auto traction is being performed with these devices:

Question: Can the use of a chiropractic roller table that is an adjustable device used to create a massaging effect along the spine be reported with code 97012?

Answer: No, the chiropractic roller table is a device that has adjustable mechanical rollers requiring stationary, supine positioning of a patient. The rollers can be adjusted for height and do not require constant one-on-one attendance with the patient to create a massaging effect along the spine. Tension via the adjustable rollers can create traction forces resulting in separation between vertebral joint surfaces. A review of the literature at the time of this printing does not support a roller table meeting the requirement of auto traction that requires the use of the body’s own weight to create sufficient force allowing for separation between joint surfaces, that may be reported with 97012, Application of a modality to one or more areas; traction, mechanical.

Therefore, code 97039, Unlisted Modality (specify type and time if constant attendance), should be reported. When reporting an unlisted code to describe a procedure or service, submit supporting documentation (e.g., procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the service.

Medicine: Physical Medicine and Rehabilitation July 2020 pages 13-14

Not so fast

It’s important to keep in mind that CPT® coding is coding, and advocacy is advocacy. Coding rules put forth by the CPT® Editorial Panel of the American Medical Association (AMA) and approved by the Center for Medicare and Medicaid Services (CMS), may not be the end of the story.

These are coding guidelines, and sometimes AMA and CMS don’t even agree. Such is the case with the direction on the recent Prolonged Services codes. They each promoted a separate code set to report these services.

When it comes to roller table traction, the AMA CPT® Assistant, in a coding clarification, indicated that it wouldn’t be appropriate to code this as 97012, Mechanical Traction. However, we’d like to call your attention to a court case (Blue Cross/Blue Shield of Rhode Island vs. Korsen) in which roller table traction was allowed to be billed as 97012. This is a prime example of precedent being set outside of coding rules.

Payers may choose which guidelines to follow and can set the rules they feel are appropriate. This is an excellent example of someone who fought back and won.

Most common coding missteps

When reviewing records and assisting doctors with auditing, we often notice a distinct pattern of consistent miscues where coding is not supported by documentation. Here is a list of the most common coding issues found and what you can watch for to raise your coding and documentation game:

Commonly Used Code Frequent Errors Found
General Coding Errors ·         Billing incorrect unit numbers for time-based codes

·         Time missing in the documentation for modalities and procedures

·         Service provided by unqualified team member

97014/G0283: Electrical Stimulation ·         Billing more than once per patient encounter, regardless of areas treated

·         Billing using 97014 when the payer requires the alternative HCPCS code G0283

97012: Mechanical Traction ·         Billing roller table traction to a payer that deems it experimental

·         Coding 97012 when using a static traction block

·         Billing 97012 when performing flexion distraction technique, in addition to the adjustment code

S8948: Low-level Laser ·         Billing a payer when the service is listed as experimental in the medical review policy

·         Using an unattended laser and billing as though attended using this code

·         Passing the cost along to the patient without acknowledgement to self-pay agreed upon prior to treatment

97110: Therapeutic Exercises ·         Documentation missing specific exercise, location, time, reps, or muscle groups

·         Documentation missing who provided the service

·         Evidence of more than one patient being supervised by the provider of service at the same time

97112: Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (NMR) ·         Billing for massage or muscle work and coding as NMR

·         Documenting standard therapeutic exercises that are not aimed at the context of the code

97124/97140: Massage and Manual Therapy ·         Service performed by someone other than the DC when the payer indicates it must be performed by the DC

·         Billing for the service when performed in the same or a contiguous body region as the adjustment

·         Documenting basic massage and billing as 97140, Manual Therapy

This is not an exhaustive list and certainly not all-inclusive, but use these examples to self-check your documentation to ensure chiropractic coding and billing compliance.

Coding from documentation is critical to the compliance process. Continuous improvement processes necessitate perfecting the art of documenting and then choosing correct codes using all the tips and hints provided here. Self-auditing periodically as part of a compliance program provides the insight that’s needed to keep your documentation and coding on the right track. Where much is given, much is required. In the land of health care reimbursement, strive to follow the rules of coding and medical necessity to stay confident about your role in the process.

KATHY WEIDNER, MCS-P, CCPC, CCCA, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist and a Certified Chiropractic Professional Coder. Since 1983, 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 our profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM-KMC or [email protected]



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