Pinpoint Common Chiropractic Coding Procedure Errors

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

Note: This article takes a purely CPT® approach to code selection and ignores the potential for varying code results based on contrary controlling guidance from the carrier or controlling reimbursement statute  or the inclusion of the S codes in HCPCS Level II by the carrier or the controlling reimbursement statute.

The most common mistake when coding therapeutic services is failure to distinguish whether the service is classified as a modality or as a procedure.

The CPT® Editorial Panel clearly defines these terms. A service is a modality where some physical agent such as light, electricity, mechanical force, or temperature is responsible for causing biologic change in the tissue. By contrast, a service is classified as a procedure where the skill of the physician or therapist is necessary during the service delivery to cause therapeutic change for the purpose of improving function.

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Put in the context of the relative value system, when the physician’s relative work is limited to determining the settings of some device that will deliver the physical agent, the service is a modality. When the therapist’s skill during the therapeutic service’s delivery is the determining factor behind the change that occurs, the service is a procedure.

Evaluating Contact

Presuming you conclude a service is a procedure (as opposed to a modality), your next task is to evaluate the contact level provided. To do so, you’ll need to understand what constitutes contact.

The American Medical Association (AMA) has clarified in the CPT® Assistant (Physical Medicine and Rehabilitation, November 2001) that contact can be visual, verbal, or manual. As noted in the definition of a procedure, direct one-on-one contact must be provided. Contact associated with certain procedures may be provided to more than one patient at a time; however, when this is the case, report the group therapy code 97150 Therapeutic procedure(s), group (2 or more individuals). Even when group therapy is provided, skilled contact is required.

Therapeutic procedures, by definition, require the skilled interaction of the physician or therapist to achieve a particular therapeutic change, so providers should be cautious about sitting in their office and watching patients exercise on the rehab floor. While visual contact no doubt exists, there is a notable lack of the skilled contact necessary to ensure the exercise will achieve its therapeutic purpose. Watching a patient doing an exercise incorrectly requires no skill at all. When clinical skill is not provided or necessary, most carriers would conclude the service is not correctly reported as a therapeutic procedure.

This issue often arises in the context of rehabilitative exercises and activities. Most insurance carriers, including Medicare, do not permit reimbursement for unskilled rehabilitative services. The reason is simple: Most physicians and therapists involved in physical medicine agree that an exercise done improperly is more likely to create dysfunction than resolve it. As a result, the ability to assign a procedure code to a service is vested in the idea that skilled interaction was not only necessary to achieve a specific therapeutic change, but that such skilled contact was actually provided.

Define the Therapy’s Intention

After establishing that skilled contact is necessary and has been performed, the final task when selecting the appropriate procedure code is to define the intention of the specific therapeutic change.

Unlike modalities, which are coded on the basis of how they are performed, procedures are reported on the basis of the therapeutic outcome intended. As such, when ordering therapeutic procedures, it is critical to document the therapy’s intended outcome in the therapy order. Without this information, it becomes impossible to assign the appropriate procedure code with certainty.

When descriptions of the various procedures are reviewed, it is difficult to appreciate how one differs from another. Because of this, providers traditionally take a particular exercise and code it using a certain procedure code, regardless of the intended therapeutic change. Unfortunately, this often leads to coding errors.

The AMA CPT® Information Service Division published guidance with the release of these codes in 1995 (CPT® Assistant, “Significant Revisions, Physical Medicine and Rehabilitation,” Summer 1995). This guidance supports the proposition that the therapy’s intended change is the basis for procedure code selection. By virtue of the examples provided, this has created some confusion as well. As an example, consider CPT® guidance for 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility:

“Therapeutic exercise incorporates one parameter (strength, endurance, range of motion or flexibility) to one or more areas of the body. Examples include treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility), and gymnastic ball (for stretching or strengthening)” [emphasis added].

The goal of improving one of the following; strength, endurance, range of motion, or flexibility through exercise service makes a rehabilitative service a therapeutic exercise. AMA provides examples of services that might accomplish such an outcome, but unwittingly creates confusion, as well. Many readers have misinterpreted the examples of what might constitute a therapeutic exercise to be an instruction that these exercises are to always be coded using CPT® 97110. Reading carefully, this is not what the guidance says: Where one of the example exercises such as a gymnastic ball is performed with the intent of improving a single parameter (strength, endurance, range of motion, or flexibility) the exercise is reportable using 97110, assuming the time and contact requirements are met.

Review the guidance with respect to CPT® 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes:

“Dynamic activities include the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity. Examples include lifting stations, closed kinetic chain activity, hand assembly activity, transfers (chair to bed, lying to sitting, etc), and throwing, catching, or swinging: Functional activities specifically related to work (hardening/conditioning) should be coded using 97545.”

Report a gymnastic ball (a technique of performing lumbar stabilization exercise in some cases) used to cause multiple therapeutic changes with 97530.

Selecting the right code is dependent on the therapy’s intended outcome for the exercise. Coders should look to the therapy care plan to determine the therapeutic purpose of each exercise. Providers, when drafting therapy care plans, must be certain to document the intended outcome for each exercise ordered. Where they do not, accurate code selection becomes difficult, if not impossible.

Most Commonly Misused Code: 97112

The most common therapeutic procedure coding error revolves around the use of 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 [emphasis added].

Breaking down the description from an outcome perspective, there must be a neuromuscular problem requiring skilled intervention to permit the patient to sit or stand. The AMA’s CPT® Assistant (Summer 1995) provides additional guidance regarding the use of this procedure, as follows:

“Examples include Proprioceptive Neuromuscular Facilitation (PNF), Feldenkreis, Bobath, BAPS Boards, and desensitization techniques.”

The AMA’s clinical vignette provided in CPT® Assistant to describe 97112 is even more instructive:

“A woman has a right CVA resulting in a left spastic hemiplegia. Although she can move her left arm, she has no functional use of it, as her increased muscle tone results in a flexion synergy in which she adducts her shoulder, flexes her elbow, and pulls her hand into a tight fist. In order to diminish the spasticity during her daily activities, the provider applies deep pressure to the patient’s biceps. The provider then internally rotates the patient’s upper arm, extends the elbows, pronates the forearm and extends the patient’s fingers and thumb. This combination of movements releases the spasm, and with manual guiding from the provider, the patient is able to practice grasping, holding and releasing large objects.”

There is a strong focus on the neurologic outcome’s intention with use of CPT® 97112. The example techniques referenced are not always reportable using 97112. The outcome is the determining factor, not the method of performance. For instance, the use of biomechanical ankle platform system (BAPS) boards is not always reported with 97112: When used to address strength, endurance, range of motion, and/or flexibility, the code result will be 97110 or 97530, as discussed above.

A review of carrier medical policy supports the conclusion that 97112 is appropriate only when the neurologic change is the primary outcome of the rehabilitative service. Consider the following medical policy published by Aetna (Aetna, CPB 0325, www.aetna.com/cpb/medical/data/300_399/0325.html, accessed 5/13/2010):

“Neuromuscular Reeducation – This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception to a person who has had muscle paralysis and is undergoing recovery or regeneration. Goal is to develop conscious control of individual muscles and awareness of position of extremities. The procedure may be considered medically necessary for impairments which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity) that may result from disease or injury such as severe trauma to nervous system, cerebral vascular accident and systemic neurological disease [emphasis added]. Standard treatment is 12 to 18 visits within a 4-6 week period.” It is not considered medically necessary to provide neuromuscular reeducation [sic], kinetic therapy, and/or therapeutic exercises on the same day.

There are many techniques, manual and otherwise, that commonly are miscoded as 97112—keying off of supposed or actual secondary “proprioceptive benefits.” When you stay focused on the type of condition – for example, evidence of sitting or standing impairment – and validate that the primary therapeutic outcome is resolution of a significant neurologic deficit, mistakes with this code can be avoided.

Other Factors to Consider

Although reimbursement between varying procedures doesn’t change much, issues arise when the code selected is inaccurate. These include whether one-on-one skilled contact was provided, whether the service was performed long enough to be reportable, and—assuming National Correct Coding Initiative (NCCI) edits apply—whether the improper code choice permitted the provider to avoid an edit that otherwise would have resulted in non-payment.

Beyond these issues, when billing separate procedure codes for various aspects of the rehabilitative session is not justified, code correction may result in fewer service units (based on time) than originally reported. Explaining each of these issues would fill the space of another article.

For coding staff to properly assign the proper therapeutic procedure code, providers must understand that providing skilled contact on a one-on-one basis and accurately reflecting the intended therapeutic outcome is necessary for each exercise ordered.

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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