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.
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.