Chiropractic Medical Billing

When it comes to medical billing and coding for any specialty, accuracy of diagnostic and procedural codes is of utmost importance. Accurate billing ensures your practice timely reimbursement as well as protection from any kind of related litigation.

Medicare Coverage for Chiropractic Treatment

Medicare reimburses chiropractors only for spinal manipulation procedure provided to correct a subluxation. It is also necessary that this subluxation is validated through X-ray or physical examination. Medicare also requires the chiropractor to indicate clearly the level of subluxation on the claim and list it as the primary diagnosis. The neuromusculoskeletal condition necessitating the treatment would be the secondary diagnosis. Medical necessity for the spinal manipulation has to be substantiated by providing the correct diagnostic codes or the ICD-9 codes. Moreover, the treatment has to be legal in the state where it is performed.

Any diagnostic procedure a chiropractor may order to prove a subluxation of the spine including X-rays is not covered; these can be used only for documentation purposes. Medicare does not reimburse services such as lab tests, nutritional supplements, office visits, traction, examinations, supports and more provided by a chiropractor.

Coming to spinal manipulation, Medicare covers up to 12 chiropractic manipulations per month, and 30 chiropractic manipulation services per year for each patient. Again, medical necessity has to be established if these services are to be properly reimbursed.

• 98940 -- Chiropractic manipulative treatment (CMT); spinal, one to two regions
• 98941 -- Chiropractic manipulative treatment (CMT); spinal, three to four regions
• 98942 -- Chiropractic manipulative treatment (CMT); spinal, five regions
• 98943 -- Chiropractic manipulative treatment (CMT); extraspinal, one or more regions

Coverage by Private Insurers

Private payers might reimburse a global fee for chiropractors. In this case chiropractors are eligible for a certain fee for each visit, whatever be the services provided or CPT codes billed. Chiropractors may also bill for modalities apart from the manipulation and office visit codes, these modality codes are 97010 - 97530, which are reimbursed by some insurance companies.

Physical medicine modalities a chiropractor may report include supervised and constant attendance modalities.

Supervised Modalities

Supervised modalities do not demand personal contact with the healthcare provider, and are eligible only once per date of the service.

• 97010 Application of a modality to one or more areas; hot or cold packs
• 97012 Application of a modality to one or more areas; traction, mechanical
• 97014 Application of a modality to one or more areas; electrical stimulation
• 97016 Application of a modality to one or more areas; vasopneumatic devices
• 97018 Application of a modality to one or more areas; paraffin bath
• 97022 Application of a modality to one or more areas; whirlpool
• 97024 Application of a modality to one or more areas; diathermy (e.g., microwave)
• 97026 Application of a modality to one or more areas; infrared
• 97028 Application of a modality to one or more areas; ultraviolet

Constant Attendance Modalities

Constant attendance modalities are time based and require direct individual contact with the service provider.

• 97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
• 97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes
• 97034 Application of a modality to one or more areas; contrast baths, each 15 minutes
• 97035 Application of a modality to one or more areas; ultrasound, each 15 minutes
• 97036 Application of a modality to one or more areas; Hubbard tank, each 15 minutes
• 97039 Unlisted modality (specify type and time if constant attendance)

Therapeutic Procedures

Chiropractors may also report therapeutic procedures; these are time based and require direct contact with the service provider. Some of these are:

• 97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)

• 97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

• 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

• 97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes

• 97542 Wheelchair management (e.g., assessment, fitting, training), each 15 minutes

Chiropractors can bill a separate E&M code on occasions such as visit of a new patient, or an established patient presenting with a new injury, re-injury/recurrence, exacerbation, or for a re-evaluation to decide whether any modification in the treatment plan is required. When billing your services, your exam is to be coded correctly, and then Modifier -25 has to be added under the modifier section. This will clarify that the medical examination was a service distinct from your therapeutic manipulation procedure and therefore should be paid in addition to the adjustment. Medicare does not reimburse chiropractic maintenance therapy.

Use of Modifier -59 (Distinct Procedural Service) by Chiropractors

Modifier -59 is used to report a procedure or service that is distinct or independent from other services provided on the same date. Physical medicine modalities provided just to relax and prepare a patient for manipulation will not be separately reimbursed when they are reported on the same day as the manipulation. On the other hand procedures such as hot/cold packs (97010), massage (97124), and/or manual therapy (97140) performed on separate body regions unrelated to the manipulation procedure, are eligible for separate reimbursement. You have to append the modifier -59 to the appropriate code. When this modifier is used along with any other modifier, ensure that -59 is reported first.

Advantages of Professional Services

• In-depth knowledge of exclusions/exceptions related to a particular code
• Excellent awareness of all requirements pertaining to accurate billing and coding
• Professionals stay constantly updated regarding changes in codes, and related rules and regulations
• Knowledge regarding Medicare rules as well as those of private payers.

New Developments

• Chiropractors are required to use ICD-10 codes on electronic as well as paper claim transactions, providing the dates of service for all procedures done after October 1, 2013. Failure to include this might lead to claim rejection.

• Regarding HIPAA compliance, with effect from January 1, 2012, for all electronic transactions including eligibility enquiries, remittance advices and claims, Version 5010 format has to be used instead of the current standard Version 4010/4010A1. This changeover is in order to facilitate the use of ICD-10 codes which are going to be implemented soon.

Therefore all electronic health transactions are to be done according to Version 5010 to avoid delay in payment due. June 15, 2011 has been declared by Medicare as the National Testing Day for the 5010 conversion.