Pinpoint Common Chiropractic Coding Modality Errors

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, CRA

Those unfamiliar with chiropractic coding often assume there’s not much to it. The chiropractic scope of practice varies from state to state, and in many states is quite broad. The chiropractic coder must be knowledgeable about evaluation and management (E/M), electro-diagnostic, radiology, musculoskeletal diagnostic, physical medicine, and manipulative service coding.

Evaluation and Management – CEMC

With respect to physical medicine services, there are a number of common mistakes. Vague code descriptions may cause confusion. When controlling carrier rules are absent, look to American Medical Association (AMA) clarifications for guidance. Most errors arise from failure to evaluate the nature of the service provided—specifically, whether the service is classified as a modality or procedure. Where modalities are concerned, providers often fail to consider whether the modality requires supervision or constant attendance.

Define Your Terms

First, consider the difference between modalities and procedures, as defined in the Physical Medicine and Rehabilitation section of the CPT® manual. Modalities are “any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electrical energy.” Modalities may be classified either as supervised or constant attendance.

A supervised modality “does not require direct (one-on-one) patient contact by the provider,” and describes codes 97010-97028. A constant attendance modality “requires direct (one-on-one) patient contact by the provider,” and describes codes 97032-97039.

Play it safe: The definitional requirement for one-on-one contact is somewhat misleading because both the AMA and the Centers for Medicare & Medicaid Services (CMS) indicate in a separate clarification that constant attendance can be provided to more than one patient at a time. Taking a literal definition of constant attendance is best; however.

Although we will not address procedures in this article, it’s important to know how they differ from modalities. CPT® defines a procedure as “a manner of effecting change through the application of clinical skills and or services that attempt to improve function.” This definition specifically describes codes 97110-97546 and 97780-97799. Under CPT® guidelines, all procedures (except 97150 Therapeutic procedure(s), group (2 or more individuals)) require direct one-on-one contact by the provider or therapist.

The key to understanding the modality/procedure distinction is two-part. The first part involves what I call “gizmo” analysis. In short, when the physical agent is provided by some device (gizmo), and the clinical skill is limited to determining the device settings and/or the application location and duration, the service is a modality. When the therapy’s effect is more dependent on the practitioner’s clinical skill (even where a device is used during delivery of therapy), the service is classified correctly as a procedure.

The second distinction is that modality code selection is based on the physical agent used and the performance method. In contrast, procedures are reported based on the therapeutic outcome achieved, rendering the contact necessary for performance largely irrelevant when selecting the appropriate procedure code.

With these definitions and distinctions in mind, let’s analyze some common modality coding errors.

Laser Therapy

Laser therapy is a modality (a gizmo delivering the physical agent causing biologic change) and, in most cases, requires constant attendance (someone has to hold the laser probe). Often it is coded incorrectly as infrared therapy. Although the light spectrum is similar, there are two potential problems when using 97026 Application of a modality to 1 or more areas; infrared for laser therapy.

1.) Infrared is a supervised modality, whereas laser therapy in most cases requires constant attendance.

2.) Infrared is a thermal/heating modality, whereas laser is not (unless a Class IV laser is used). The thermal aspect of infrared is not part of the code description; however, CPT® Assistant—although not likely controlling—clarifies that infrared is a “Modality which uses light and heat to rinse [sic] the tissue temperature 5 to 10 degrees centigrade in the area of application” (Summer 1995, page 5).

You should report cold laser therapy using 97039 Unlisted modality (specify type and time if constant attendance). As per the code descriptor, document the time of performance. The service can be reported in multiple units where sufficient time is documented.

Many carriers challenge services reported using an unlisted code such as 97039, and may deny payment on the basis that laser therapy is experimental/investigational. Such a determination permits you to bill the patient directly, and lowers the risk that the carrier will demand a future refund on the basis that the service was misrepresented using 97026.

If the carrier has adopted HCPCS Level II private payer S codes into its code set, you would instead report cold laser therapy requiring constant attendance using S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes.

Mechanical/Vibratory Massage

At times, providers use mechanical devices providing vibration/percussion to alleviate paravertebral or other muscle hypertonicity or tension. Devices may be handheld or involve more elaborate tables or chairs. Because these devices are claimed to cause similar therapeutic effects as massage, they often are miscoded as 97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion). Applying the above modalities and procedures definitions, however, these services are classified correctly as modalities because the biological change is caused by the physical agent applied (mechanical vibration, percussion), and no particular clinical skill is necessary to achieve this result.

Code 97016 Application of a modality to 1 or more areas; vasopneumatic devices is also inaccurate. Although not likely controlling, CPT® Assistant (Summer 1995, page 5) advises, “These devices incorporate suction type force to the soft tissues being treated. Vasopneumatic devices are also used to describe pumps that decrease edema in extremity tissues. Examples include the Jobst Pump, Vibromassage, and Interferrential Pump.” Although vibromassage might qualify for 97016, CPT® Assistant later clarified in a “Coding Consultation: Question and Answers” segment (May 2005, page 14):


“What is the appropriate CPT® code to report for mechanical massage therapy?”

AMA Comment

“From a CPT® coding perspective, no current CPT® code specifically and accurately describes mechanical massage; therefore, code 97039, Unlisted modality (specify type and time if constant attendance), would be the most appropriate code to report for mechanical massage therapy. It would not be appropriate to report code 97124, Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).”

Although the AMA appears to contradict itself, the result is accurate. Vibromassage is a suggested example of what might constitute a “pump that decrease[s] edema in extremity tissues.” Clearly, it was not envisioned that a vasopneumatic device would be used in the spinal region according to the 1995 publication, and possibly the inclusion of vibromassage as an example in 1995 was erroneous where the guidance published in 2005 is considered. There is little evidence that such devices provide a vasopneumatic effect. Breaking the term into its parts and defining each, we find such a device provides some vascular effect using air. Given that air (specifically, air pressure) is the physical agent at issue with 97016, and that mechanical vibratory massage devices use a pure mechanical percussion or vibratory force as the physical agent, it is reasonable to conclude that CPT® 97016 is not the appropriate code for this service.

Even if we conclude such devices are pneumatic, CPT® 97016 is still improper when a hand-held device is used. CPT® 97016 requires supervision, not constant attendance. A hand-held vibratory percussion device requires constant attendance. Because no existing constant attendance code describes the physical agent at issue, 97039 is still correct.


CPT® 97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes is appropriate for iontopheresis only. CPT® Assistant defines iontopheresis as “the introduction of ions of soluble salts into the body by an electric current.”

Some providers and coders incorrectly report iontopheresis on the basis of applying topical gels such as Kool Comfort® or Biofreeze® to the skin prior to electric stimulation pad application. The main problem here, despite the absence of ions from soluble salts, is that constant attendance isn’t required with this application type. The second, less obvious issue is related to the introduction of ions from soluble salts. McDonald J., Lundgren K., Thieme H., Clinical Protocols, page 48 (Clinical Education Associates, 1996) describes this service:

“Direct current has been used extensively to drive ions from the heavy metals into and through the skin for treatment of skin infections or for a counter-irritating effect. There are three techniques of application:

1. An active pad is placed over gauze that is saturated with a solution containing the ions,

2. The active electrode is suspended in a container containing the ion solution, then the part to be treated is immersed in the container or,

3. Special stimulators with a specially adapted electrode containing the treatment ions is positioned as close to the involved tissue as possible. In all cases a large dispersive pad is applied to the patient and the proper polarity of the active electrode is selected based on the polarity of the ions in the solution.”

Because there is a significant risk of burning the patient’s skin, constant attendance is required. This therapy is used primarily by dermatologists to treat skin conditions, but may be appropriate to reduce inflammation. The variations between this form of therapy and traditional forms of electric stimulation are distinct:

1. Direct current is utilized and is passed from an active pad or electrode through the skin to a diffusion pad. Most forms of electrotherapy involve alternating current flow between two or more pads where each is an active pad.

2. Special pads containing the treatment ions are used, or a pad placed over gauze saturated with a solution containing the ions is used.

3. True iontopheresis requires constant attendance based on the patient’s risk of being burned; traditional forms of electric stimulation do not.

Hands-Free Ultrasound

Ultrasound is a constant attendance modality that uses sound waves to increase tissue temperature. CPT® Assistant (Summer 1995, page 5) reports, “This modality is used in the treatment of arthritis, neuromas, adhesive scars, and where increasing the tissue temperature is the desired effect.”

Continuous ultrasound (97035 Application of a modality to one or more areas; ultrasound, each 15 minutes) clearly provides such a thermal effect, while pulsed ultrasound generally is considered a non-thermal form. Continuous vs. pulsed forms of ultrasound raise interesting coding issues. Consider the description of pulsed ultrasound in Clinical Protocols, pages 89-101:

“Soundwave propagation is intermittent, retaining the mechanical effects of mild cavitation and micro massage without any thermal effects [emphasis added]. Pulsed ultrasound is beneficial in acute conditions, inflammatory responses, nerve entrapment and neuromas in scar tissue.”

Because of the lack of thermal effect with pulsed ultrasound, questions arise regarding the need for or provision of constant attendance. Currently, some pulsed ultrasound units are marketed as hands-free devices. The ultrasound head is on a mechanical arm placed over the patient. Even when argued that pulsed ultrasound can provide or is providing some thermal effect, if the therapy can be or is delivered in a supervised setting, 97035 is inappropriate. In these cases, constant attendance is not required. When ultrasound can be provided in a supervised setting, report 97039.


Phonopheresis is often misreported as an unlisted procedure (97039) on the basis that it is not a modality per CPT®. Phonopheresis is simply a fancy word for ultrasound where a steroidal cream is used in place of the usual conductive gels. CPT® Assistant (Summer 1995, page 5) advises, “If ultrasound therapy is used with a steroid cream, 99070 should be added, in addition to 97035, for use of the steroid cream.”

Either way, ultrasound (97035) is reported, assuming constant attendance is required and maintained. The only difference is the separate reporting of the steroid cream using the generic supply code 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).

Although CPT® definitions and clarifications found in the CPT® Assistant are not part of the Health Insurance Portability and Accountability Act (HIPAA)-mandated code set, application of these basic principles of modality analysis provide a sound foundation for code selection. Always be on the lookout for differing carrier standards, and follow written carrier guidance.

Note: This article considers AMA/CPT® guidelines only. Coding may vary depending on the existence of contrary controlling guidance from the carrier, a controlling reimbursement statute, or the inclusion of the S codes in HCPCS Level II by the carrier or the controlling reimbursement statute.


Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, is president of Practice Masters, Inc. and the founding partner of Miscoe Health Law, LLC, a member of the AAPC Legal Advisory Board (LAB) and a past member of National Advisory Board (NAB). He is admitted to the Bar in the state of California and to practice law before the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. Mr. Miscoe has nearly 20 years of experience in health care coding and over 14 years as a compliance expert testifying in civil and criminal cases.

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