Monthly Archives: October 2014

Denial of E&M Code with Chiropractic Manipulation

Examination denials

I had a denial for the examination (99203) of brand new patient. On the EOB it stated that “the service billed is included in another procedure billed the same day.” I do not understand this denial as I am required to do an exam to determine the condition of my patient and formulate a treatment plan. I did perform an chiropractic treatment in the same visit, but that code was for my specific manipulation service. Are they right, do I not get paid for an exam when I bill it with treatment? If not, what did I do wrong and how can I get my examination paid?

You are correct in that you must perform an examination to determine the patient’s condition and course of care plan. But a common error when billing for an examination the same day as treatment is to not include the modifier -25 on the exam code (in this case 99203-25). This modifier is certification that a significant, separately identifiable evaluation and management service (examination) was performed the same day.

The reason this modifier must be applied is that all chiropractic manipulation codes have an included component that is a pre-service, intra-service and post-service, assessment. This assessment is for the typical short history and evaluation done on each visit, prior to and after the day’s treatment. This assessment is not intended as the more extensive evaluation done on the first visit and re-examinations. It is for this reason that an examination (evaluation and management code) is not to be billed on every visit.

To correct this claim you must resubmit the billing with the proper modifier (25) so it will be separately reimbursed. Including a copy of the examination with the re-billing is also useful, as will avoid further delays should the insurance want to view the record of the separate examination.

Extraspinal CMT Performed Same Date as Spinal CMT

I have always been under the premise that when billing 98943, extraspinal chiropractic manipulations, on the same visit as spinal manipulation 98940-98942, that the extraspinal manipulation requires modifier 51. However I recently received a denial from United Health Care that the modifier was improper. Is there a requirement to use 51 modifier with this combination of coding?
From the initial adoption of the current CMT codes 98940-98943 there has been a general acceptance that when extraspinal was billed with spinal that the extraspinal manipulation code is to be appended with modifier 51. This modifier was often thought by many chiropractors that it indicated a separate distinct manipulation and in fact that assumption was incorrect.
Modifier 51 (multiple procedures) is used to inform payers that two or more procedures are being reported on the same day. A claim form (CMS 1500) that has modifier 51 appended to a CPT code(s) tells the payer to apply the multiple procedure payment formula to the CPT code(s) linked to the modifier 51. Therefore in actuality it was not to inform that a separate service was done but that multiple procedures were done and that a fee reduction applies. This is why United Health Care reduced the fee of 98943 by 50% as it was the use of the 51 that indicated such.
Clearly 98940-98942 compared to 98943 are distinctly separate as the former indicates manipulation to the spine and the latter to an extraspinal region. Clearly and based on the code description a modifier was not needed to indicate they are separate and if it did the modifier would be 59 not 51. Per the CPT description and definition of modifier 51, is not appropriate for use with E&M services or physical medicine rehabilitation services. Of course chiropractic manipulation is neither an E&M code nor physical medicine rehabilitation service but would appear to fall in the same range and likely it too should not be used.
Then why would a carrier require it for a CMT as a multi-procedure when it is not used for any other services that fall under physical medicine? The answer appears to be simply it allows a 50% reduction of the fee. In my opinion the use of 51 always appeared inappropriate as the services are clearly separate and while the pre-manipulation assessment associated with CMT is part of the overall service there is distinctly a separate premanipulation to extraspinal regions that would not be included in the spinal regions. And furthermore there should not be any reduction of the fee to extraspinal simply because spinal manipulation was done. The premanipulation assessment for the spine does not include what is necessary to assess nor manipulate an extraspinal region a reduction of fee on that basis would seem improper.
While many if not most carriers have abandoned the need and use of the 51 there were several carriers that maintained the requirement. Specifically United Health Care (Optum Health), as you noted, did so. However they recently eliminated the need due to AMA, The CPT® Assistant, who made a definitive statement on need for the 51 modifier with chiropractic manipulation.
According to “The CPT® Assistant” [December 2013], these are separate and distinct procedures and the use of modifier 51 does not apply. Modifier -51 (Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940- 98943). Due to the definitive nature of the publication in relating to coding of CPT this means that 51 does not apply and more importantly nor does the 50% reduction of payment.
In response United Health Care in April 20014 published that there is no longer a need for the use of the 51 modifier for extraspinal chiropractic manipulation when done in conjunction with spinal manipulation.

How to Properly Bill for Flexion Distraction

I am very confused as to how to code the use of flexion-distraction. I have always billed it as traction but just recently heard that coding it in that manner was incorrect. What is the code that should be used for this type of service?

The coding of this service is often confused and misunderstood. I think mainly because of the term used to describe it “flexion-distraction”. Once we see that language it is common to think traction and bill it under the codes for traction. However, that is an incorrect assumption.
The coding for flexion-distraction is in fact chiropractic manipulation. Chiropractic manipulation 98940-98942 can be broadly organized into various styles of manipulation and mobilization. The best description of Flexion-Distraction technique using existing Current Procedural Terminology language and codes would be the CMT codes, 98940, 98941, or 98942. As described by Dr. Cox, an originator and arguably the technique’s name sake “Cox Flexion-Distraction” it is a method of chiropractic manipulation that uses a long axial forces.

While many chiropractors may indeed use this method as an additional source of treatment to their own chiropractic technique and see it as more a method of “traction” than a manipulation, it is manipulation none the less. The coding for this service in this manner is also substantiated by the statement and interpretation from the American Chiropractic Association (ACA), which too indicates flexion distraction, is to be coded under chiropractic manipulative therapy codes.
Per the ACA “Flexion distraction is a Chiropractic Manipulative Technique. Per the preamble of the CMT code set (98940-98943) it is a procedure that is a form of manual treatment to influence joint and neurophysiological function. The physician work included in CMT codes was laid out in a work value survey of the chiropractic profession conducted in the spring of 1996 and included the work of flexion distraction. The procedure is taught in the curriculum in accredited chiropractic programs and institutions. Therefore, the appropriate coding for this technique is 98940, 98941, or 98942, depending on the number of other body regions treated”.

Therefore if billing for traction under this code and your file was audited and noted that the service being billed under traction was indeed flexion-distraction there could be request for a refund as that service under flexion distraction was part of another service, namely and assuming 98940-98942 was billed that date of service. If no manipulation code was billed it may still be refuted as the incorrect code for the service provided, however manipulation is generally a higher valued service and no net refund may be necessary.