Add Therapeutic Procedures and Modalities to a Chiropractic Practice
It’s a worthwhile venture, but document and code claims carefully to get paid.
By Marty Kotlar, DC, CHCC, CBCS
Adding therapeutic procedures and modalities can be a great adjunct to a chiropractic practice. Many doctors of chiropractic medicine incorporate therapeutic procedures and modalities, and most insurance carriers (except Medicare) will reimburse chiropractors for them.
Supervised modalities include application of a modality to one or more areas not requiring direct (one-on-one) patient contact by the provider. Supervised modalities examples include:
Mechanical traction (97012 Application of a modality to 1 or more areas; traction, mechanical) is used to separate and stretch the spinal segments, promote distraction, and gliding of the joint facets to help promote joint hydration.
Electrical stimulation, unattended (97014 Application of a modality to 1 or more areas; electrical stimulation (unattended) and G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care) is used to treat edema, inflammation, muscle spasm, limited mobility, atrophy, wound care, and re-education of muscle function.
Constant Attendance Modalities
Constant attendance modalities include the application of a modality to one or more areas, and require direct (one-on-one) patient contact by the provider. Constant attendance modalities examples include:
Electrical stimulation, attended (97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes): High volt electrical muscle stimulation is used to help reduce pain and muscle spasm. It also helps to reduce inflammation and promote tissue healing and repair. Low frequency electrical muscle stimulation helps with the reduction of post-traumatic inflammation, reduces swelling, and promotes wound healing.
Ultrasound (97035 Application of a modality to 1 or more areas; ultrasound, each 15 minutes) is used to provide a deep, penetrating heat effect within the tissue. Ultrasound introduces a micro-massage within the tissue by breaking down scar tissue and reducing edema.
Therapeutic procedures affect change through the application of clinical skills and/or services to improve function. Physicians or therapists are required to have direct (one-on-one) contact with the patient.
Therapeutic procedures are generally coded and billed on the basis of the intended outcome, not on a device or piece of equipment (in contrast to modalities, which generally are coded and billed based on the device used). When billing and coding for therapeutic procedures, be sure to document the intended clinical outcome, as well as how the procedure is performed. The relationship to a functional activity is important to document in the treatment plan. An example might be, “Increase flexibility of the quadratus lumborum muscles while activating and stretching the hamstring muscles to improve the patient’s capacity for walking and standing.”
Therapeutic procedure examples include:
Therapeutic exercises (97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) are performed in either an active, active-assisted, or passive approach (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening). The exercises may be reasonable and medically necessary for a loss or restriction of joint motion, strength, functional capacity, or mobility that has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance). Therapeutic exercises are used to increase range of motion, flexibility, endurance, and strength.
Neuromuscular re-education (97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities) is used to improve balance, coordination, kinesthetic sense, and proprioception (the sense of the relative position of neighboring parts of the body and effort employed in movement.). This procedure is reasonable and medically necessary for impairments affecting the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, and hypo/hypertonicity). Examples include proprioceptive neuromuscular facilitation (PNF), the Feldenkrais method, Bobath, Bap’s Boards, and desensitization techniques.
Aquatic therapy with therapeutic exercises (97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises) are used for a loss or restriction of joint motion, strength, mobility, or function resulting from a specific disease or injury. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, or levels of assistance). Exercises are performed in a water environment and in a non-weight bearing position.
Gait training (97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)) should be used for training patients whose walking abilities are impaired by neurological, muscular or skeletal abnormalities, or trauma. This procedure should not be used when the patient’s walking ability is not expected to improve.
Massage therapy (97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)) could be used as a preparatory procedure on the same day as a therapeutic procedure to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm. It should be related to other therapeutic procedures within the overall plan of treatment. This therapy includes effleurage, petrissage, and/or tapotement (stroking, compression, percussion) and is used to reduce spasms and stiffness.
Manual therapy techniques (97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes) include soft tissue and joint mobilization, manipulation, manual lymphatic drainage, manual traction, trigger point therapy (non-injectable), and myofascial release. Manual therapy techniques are used to treat restricted motion of soft tissues in the extremities, neck, and trunk, and are used in an active and/or passive fashion to effect changes in the soft tissues, articular structures, neural, or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened connective tissue.
97124 vs. 97140
One difference between 97124 and 97140 is the intention of the therapy. If you are performing therapeutic massage to increase circulation and promote tissue relaxation to the muscles, and the treatment is based on or consists of a basic relaxation massage, use 97124. If, however, your intention is to increase pain-free range of motion and facilitate a return to functional activities, use 97140.
Be aware, also, of the National Correct Coding Initiative (NCCI) edits created by the Centers for Medicare & Medicaid Service (CMS), which require manual therapy techniques, massage therapy, and neuromuscular re-education be performed in a separate anatomic region than the chiropractic adjustment. When appropriate, attach modifier 59 Distinct procedural service to 97112, 97124, or 97140 to indicate it is a distinct procedure and is being performed on a different anatomic site than the chiropractic manipulative therapy (CMT).
Billing for Units
For any single timed CPT® code on the same day measured in 15-minute units, billing for units is as follows:
1 unit = 8-22 minutes
2 units = 23-37 minutes
3 units = 38-52 minutes
4 units = 53-67 minutes
If a service represented by a 15-minute timed code is performed in a single day for at least 15 minutes, bill that service for at least one unit. If the service is performed for at least 30 minutes, bill that service for at least two units, etc.
It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service (as noted in the chart on the previous page) determines the number of timed units billed.
If any 15-minute timed service performed for seven minutes or less on the same day as another 15-minute timed service also performed for seven minutes or less, and the total time of the two is eight minutes or greater, bill one unit for the service performed for the most minutes. Apply the same logic when three or more different services are provided for seven minutes or less.
The expectation is that a provider’s direct patient contact time for each unit will average 15 minutes in length. If a provider has a consistent practice of billing less than 15 minutes for a unit, these situations could be highlighted for review. If more than one 15-minute timed CPT® code is billed during a single calendar day, the total number of timed units that can be billed is constrained by the total treatment minutes for that day.
The amount of time for each specific modality and therapeutic procedure provided to the patient should be documented in the subjective, objective, assessment, and plan (SOAP) notes.
Example No. 1
8 minutes of therapeutic exercise (97110)
8 minutes of manual therapy (97140)
TOTAL = 16 timed minutes
The appropriate billing in this example is one unit. You should select 97110 or 97140 to bill because each unit was performed for the same amount of time and only one unit is allowed.
Example No. 2
7 minutes of neuromuscular re-education (97112)
7 minutes of therapeutic exercise (97110)
7 minutes of manual therapy (97140)
TOTAL = 21 timed minutes
The appropriate billing in this example is one unit. You should select one code (97112, 97110, or 97140) to bill because each unit was performed for the same amount of time and only one unit/one code is allowed.
Example No. 3
33 minutes of therapeutic exercise (97110)
7 minutes of manual therapy (97140)
TOTAL = 40 timed minutes
The appropriate billing in this example is three units. Bill two units of 97110 and one unit of 97140, and count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.
Example No. 4
24 minutes of manual therapy (97140)
23 minutes of therapeutic exercise (97110)
TOTAL = 47 timed minutes
The appropriate billing in this example is three units. Each service is performed for more than 15 minutes, so bill each for at least one unit. The correct way to code this example is two units of 97140 and one unit of 97110, assigning more timed units to the service that took the most time.
Example No. 5
18 minutes of therapeutic exercise (97110)
13 minutes of manual therapy (97140)
10 minutes of therapeutic activities (97530)
8 minutes of ultrasound (97035)
TOTAL = 49 timed minutes
The appropriate billing in this example is three units. You should bill the procedures you spent the most time providing. Bill one unit each of 97110, 97140, and 97530. You should not bill for the ultrasound because the total time that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill four units for less than 53 minutes, regardless of how many services were performed). You should document the ultrasound in the SOAP notes.
In an upcoming issue, we’ll discuss group therapy coding and coding for unlisted modalities.
Understand Medical Necessity
One of the most important items relating to therapeutic procedures and modalities is establishing medical necessity. Per the Centers for Medicare & Medicaid Services (CMS), medical necessity is a service, treatment, procedure, equipment, drug, or supply provided by a hospital, physician, or other health care provider that is required to identify or treat a beneficiary’s illness or injury, and which is (as determined by the contractor):
a. Consistent with the symptom(s) or diagnosis and treatment of the beneficiary’s illness or injury;
b. Appropriate under the standards of acceptable medical practice to treat that illness or injury;
c. Not solely for the convenience of the participant, physician, hospital, or other health care provider; and
d. The most appropriate service, treatment, procedure, equipment, drug, device, or supply which can be safely provided to the beneficiary and accomplishes the desired end result in the most economical manner.
The provided items or services must be reasonable and necessary for the diagnosis or treatment of the illness or injury or to improve the functioning of a malformed body member.
Diagnoses Done Right
Therapeutic procedures and modalities billed to insurance carriers must be supported by your diagnoses, and the diagnoses must be substantiated by documentation. The clinical rationale for choosing a diagnosis must be in writing and entered in the patient chart. The diagnoses you choose represent your patient’s condition to insurance carriers and should be extremely accurate.
Accuracy is also important when incorporating certain rehabilitation procedures. For example, if you plan on using myofascial release (97140) on the shoulder, a soft tissue diagnosis such as 719.51 Stiffness of joint, not elsewhere classified, shoulder region would be appropriate.
Insurance carriers can look for diagnosis codes that were truncated (shortened or condensed). Many carriers require diagnoses to be reported to the “highest degree of specificity.” This means that if the patient presents with a chief complaint that can be reported with a 5-digit diagnosis code, use it.
During the initial patient visit, you may come up with a “probable,” “suspected,” or “working” diagnosis. Use caution in this situation: Code to the highest degree of certainty for that patient encounter, to include signs, symptoms, subluxation levels, diagnostic test results, or other reason for the visit.
You may also face a situation when a diagnosis cannot be established at the time of the initial encounter. It’s OK to take two or more visits before a diagnosis can be confirmed. You’re better off waiting a few visits to submit a claim that has a definitive diagnosis than submitting an incorrect diagnosis code.
Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding (www.TargetCoding.com). He has been helping chiropractors with reimbursement issues using proper and compliant CPT® coding for more than 10 years. Dr. Kotlar can be reached at firstname.lastname@example.org.