For Chiropractors: Know 97140 Billing Rules
Your options can mean the difference between getting paid and not getting paid.
By Heather M. Garcia, CBCS, CMAA, CMB
Aetna has made a nationwide policy decision for chiropractic reimbursement, which states that when manual therapy (97140 Manual therapy techniques, one or more regions, each 15 minutes) is performed on the same date of service (DOS) as a chiropractic manipulative treatment (98940-98943), the manual therapy will be denied, automatically. There are two options to overcome this:
- Perform the manual therapy service on a different DOS than the adjustment (if your state scope of services permits it); or
- Submit the services together, anticipate the denial, and submit an appeal with your treatment records.
Keep in mind: Appeals will work if you are an out-of-network provider and will be less effective if you are an in-network provider. If you are in network, you have agreed to Aetna’s policies (through your contracts), and you’ll most likely need to write off reimbursement for 97140. In-network providers cannot bill the patient. Out-of-network providers can bill the patient, if necessary.
Aetna defends its policy of automatic denial. A review of services determined that 90 percent of audited patients receiving manual therapy on the same day as a chiropractic manipulative treatment had the services performed on the same region(s), although modifier 59 Distinct procedural service is supposed to be used only when the services are performed on different anatomic regions.
Apply 97410 Properly
Per CPT® guidelines, 97140 describes manual therapy techniques, such as mobilization and manipulation, manual lymphatic drainage, and manual traction. Chiropractic adjustments have their own set of codes (98940-98942, or 98943 for an extremity). If you report a subluxation diagnosis code, you must perform an adjustment — especially if you are in a state where you need a nexus to the spine to bill anything other than the adjustment.
National Correct Coding Initiative (NCCI) claim edits bundle manual therapy (97140) to chiropractic adjustment codes (98940-98942) when performed in the same anatomic region. If the procedures are performed in separate anatomic regions, you may report them separately by appending modifier 59 to the adjustment code (97410 is the “column 2” procedure). If the claim is properly filed and supported by documentation, the insurer should pay for both procedures.
Example 1: The chiropractor performs chiropractic adjustment (98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions) on the cervical region. He then performs manual therapy (97140) to the same cervical region. The patient’s diagnosis codes reflect a cervical subluxation (739.1 Nonallopathic lesions, cervical region) and muscle spasms (728.85 Spasm of muscle). The manual therapy (97140) would not be reimbursable in this scenario.
Example 2: The chiropractor performs chiropractic adjustment (98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions) on the cervical and lumbar regions. He or she then performs manual therapy (97140) on the patient’s shoulder. The patient’s diagnosis codes are cervical subluxation (739.1), lumbar degenerative disc disease (722.52 Degeneration of lumbar or lumbosacral intervertebral disc), adhesive capsulitis (726.0 Adhesive capsulitis of shoulder), and muscle spasms (728.85). The diagnosis pointers link the manual therapy (97140) to the diagnosis codes adhesive capsulitis (726.0) and muscle spasms (728.85). In this scenario, the manual therapy would be separately reimbursable if reported with modifier 59 appended.
To best support payment and minimize audit red flags, the provider’s notes should include:
- Indications for treatment (manual therapy)
- Treatment goals associated with manual therapy services
- Objective measures used to ensure patient progresses in treatment goals
- Progression towards treatment goals
- Which regions, specifically, were treated with manual therapy and with your chiropractic adjustment; these areas should not coincide if you want to receive separate reimbursement.
- Treatment plan (include frequency and duration)
Handle Aetna Appeals
Based on my experience billing to Aetna, you do not have to wait for Aetna to deny your claims for same-session manual therapy and chiropractic adjustment to file an appeal. You can send the notes with the original claim. This means you have to send the claims on paper. Paper claims have a longer processing time and this may hinder your cash flow.
If you do wait for a denial, you can get a partial payment at that time, and then wait for payment on the second code (through the appeal process). For smaller offices, it may be easier to wait for the denial because it will be easier to track the appeals. For medium to larger offices, it may be easier to submit the original claims with the notes, so you do not have to track tons of appeals. Decide what works best for your practice.
Billing Several Modalities
Note that Aetna usually only allows payment for four modalities per visit. This raises a question: If you bill for five or six modalities, for instance, and Aetna only pays for four modalities, should you bother appealing 97140?
I suggest you don’t have to appeal because you won’t receive additional compensation, in any case. But be aware some Aetna plans will reimburse for more than four modalities. Be sure, however, that your definition of a modality is the same as Aetna’s. For example, office visits are not part of the four-modality cap. This means that when supported by medical necessity, you can render an office visit in addition to four modalities. Just because Aetna paid on four codes, doesn’t mean they’ve paid on four modalities.
To help ensure your claims are processed correctly, in addition to sending your doctor’s notes with the original claim, use diagnosis pointers. Most billing programs default diagnosis pointers to 1, 2, 3, etc., or now A, B, C, etc., on the new claim forms, depending on how many diagnosis codes you input. Diagnosis pointing is under-utilized in billing, especially in the chiropractic world. Using diagnosis pointers can help differentiate the region(s) adjusted/manipulated from the region(s) on which the doctor performed manual therapy (97140).
Additional resources: Aetna Clinical Policy Bulletin: Chiropractic Services Number: 0107
What Are Diagnosis Pointers?
Diagnosis pointers are the numbers (now letters on the new claim form) in box 24E on the CMS 1500 form. Diagnosis pointers link the diagnosis to the applicable CPT® codes you are billing. For example, you can have three diagnosis on your claim forms but each of them go to only one of the CPT® codes you are billing for that day. It explains the reason you are performing the particular CPT® code.
Heather M. Garcia, CBCS, CMAA, CMB, has been in the medical billing and consulting business for over 13 years. She launched Smart Healthcare Solutions Corp. in 2005. Garcia has been an expert witness in New York litigation trials and has also participated in the Medical Assistant/Medical Coding and Billing Advisory Board for Lincoln Tech. She is a member of the Upper Saddle River, N.J., local chapter.
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