Sometimes we get asked the difference between diagnostic (ICD) and CPT codes. Both codes sets are used to standardize medical communications across the board, but ICD codes focus on the diagnosis, whereas CPT coding identifies the services provided. Understanding how to properly use CPT codes is really critical in helping achieve prosperous reimbursement because insurance companies use these codes to determine how much a chiropractor will be paid. The CPT section in Digital Coding is a very useful tool in helping not only select, but really understand the appropriate code to use. Digital Coding has four specific chiropractic CPT sections: evaluation and management; physical medicine and rehabilitation; x-ray, and chiropractic manipulation. Did you know that misuse of a CPT code is the #1 trigger of an audit by an insurance company? All the more reason to make sure you are using the right code, the most updated code, and are knowledgeable how to apply CPT to a chiropractic practice.
QUESTION? What's with the new modifiers that replace modifier 59? Will they allow me to be paid for 97140, manual therapy, when done with chiropractic manipulation?
ANSWER:Yes, there are 4 new modifiers for 2015 that are to replace and more clearly identify subsets of modifier 59. The effective date is January 1, 2015 with an implementation date January 5, 2015. Modifier 59 is used to indicate a “distinct procedural service” and these new modifiers further delineate the distinct nature of the service.
XE Separate Encounter: A service that is distinct because it occurred during a separate encounter
XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure
XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner
XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service
Currently, the use the -59 modifier is to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Because it can be so broadly applied, some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI)”; it is the most widely used modifier. It is also associated with considerable abuse and high levels of manual audit activity, leading to reviews, appeals and even civil fraud and abuse cases.
Modifier 59 has been prominent in chiropractic since the update of CPT code, 97250 myofascial release, to 97140 manual therapy in 1999. As I am sure you are aware manual therapy 97140, to be separately reimbursed from chiropractic manipulation must be performed to a region not being manipulated on the same visit. Regardless of the type of manual therapy when done in same region as chiropractic manipulation the services are considered bundled into the manipulation service.
Often however providers will bill 97140 with modifier 59 when the services were not performed on separate anatomic region allowing improper reimbursement for the 97140 service. Aetna indicated improper use of 59 following their investigative audits where they found that 90 percent of the time that modifier 59 was used; manual therapy was performed in the same region as the CMT. They also found very poor or lack of documentation where no specificity was indicated to establish protocol for separate reimbursement. As a consequence Aetna began to not pay for 97140 with chiropractic manipulation regardless of the modifier use. However, they did relent to some extent and began to pay chiropractors for 97140 services when additional documentation was supplied to not only include use of modifier 59 but that medical necessity and separate regions were established in the medical record. This of course required considerably more work by the provider by requiring additional clinical information on the service.
For instance under certain circumstances, it may be appropriate to additionally report CMT codes in addition to code 97140. For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code 97140 to the neck region and CMT to the lumbar region. As separate body regions are addressed, it would be appropriate in this instance to report both codes 97140 and 98940. In this example, the modifier -XS should be appended to indicate that a distinct procedural service was provided to a separate anatomical site.
CMS will continue to recognize the -59 modifier, but note per the instructions of Current Procedural Terminology (CPT) state that the -59 modifier should not be used when a more descriptive modifier is available. These codes will replace the use of modifier 59 where applicable. The use of 59 will likely result in greater audits, denials and requests for information for payment and therefore better to use the more detailed X(EPSU) modifier when appropriate.
This is particularly helpful considering the reimbursement policies of Aetna and United Health Care (Optum Health) which both specifically audit and request details for use of the 59 modifier when used with chiropractic manipulation with manual therapy.
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.