Wiki Provider/Seperate Encounter

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Linda Gonzales

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Would an employee (a non-licensed person) of a chiropractor be considered as a different provider when treatment was performed by the employee and not directly by the chiropractor? We are located in PA and under the PA Chiropractic Act certain procedures can be delegated to ancillary personnel (essentially anything other than the manipulations). Would the employee's treatment be considered as a separate encounter when it comes to the 59 modifier and NCCI edits?


Thank you in advance,
LKG/CPC
 
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Provider/Separate Encounter

Thank you for your response, could you please explain to me why it would not be considered a seperate encounter?
 
Can you please provide the documentation?
I was unaware that this was a manipulation/massage situation.
As such the non provider service is subject to the documentation of the claim.
I will temporarily withdraw my no answer pending further documentation review.
 
Thank you for the clarification:

Let's start with the standards of medical practice.
They are intended to provide a common base of understanding to foster consistency in a practice and improve quality for those interpreting services.
In so much that they are referenced in the cci edits for this code combination the purpose is to insure that the physician is not billing for codes that have overlapping components. CPT 97140 is a component code of 98941. In being so it is not to be billed unless it was performed on a separate anatomical site, a separate injury or a different session.

I was looking for documentation of a different session. If the physician did not document that 97140 was performed at a different "time" (session) on the same day then yes you are correct in denying the claim. I have a reference to a workers compensation case in Texas that lost on appeal because a different session was not documented. When it is not documented as separate it is correct to interpret the codes as being bundled under the standards of medical practice.
But because the documentation supports (however vague) that a separate session took place then there are no overlapping components as it pertains to the standards and the claim should be reimbursed as submitted. I apologize to have switched my stand but they are correct in requesting reimbursement for their time and effort with this patient.

Here is an example from Medicare citing the use of modifier 59 in a similar situation:
Example 9: Column 1 Code / Column 2 Code - 97140/97530
>CPT Code 97140 ? Manual therapy techniques (eg, mobilization/manipulation,
manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
>CPT Code 97530 ? Therapeutic activities, direct (one-on-one) patient contact by the
provider (use of dynamic activities to improve functional performance), each 15
minutes
Modifier 59 may be reported if the two procedures are performed in distinctly different 15
minute intervals. CPT code 97530 should not be reported and modifier 59 should not be
used if the two procedures are performed during the same 15 minute time interval.
Modifier 59 is used appropriately when the procedures are performed in different
encounters on the same day.

Here is a link:
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf
 
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