Chiropractic Coding

Many years ago when I first began my career in the health field I worked for a chiropractic office as I was becoming familiar with their computer system, codes, and billing forms I had a lot of questions! Over 15 years, work on a bachelors degree and multiple coding and billing certifications later, I realize that even seasoned providers and billers alike have much to question in the area of coding and documenting chiropractic services. We have CMS Medicare guidelines, as well as private carriers, CPT guidelines, as well as NCCI edits to follow. On top of the guidelines and policies there are several templates available for use by Chiropractors, some contained within EMR’s and some by means of free and purchasable templates found on the web. We will be taking a look at some of the problem areas associated with documentation and coding of chiropractic services, as well as some “best practice” workflows to follow.

Why Chiropractic is so Heavily Monitored

So lets take a look at some of the issues facing chiropractors and the billing of their services. Why is there a cause for concern? According to a report published by the Office of Inspector General (OIG) in 2009, “In 2006, Medicare inappropriately paid $178 million (out of $466 million) for chiropractic claims for services that medical reviewers determined to be maintenance therapy ($157 million), miscoded ($11 million), or undocumented ($46 million). These claims represent 47 percent of all allowed chiropractic claims that met the study criteria. Claims representing $36 million had multiple errors.” Wow, those are some pretty big numbers, and this study was completed back in 2009, on dates of service for 2006. So what is the current story on Medicare costs for chiropractic? There hasn’t been another OIG investigation and report on this data, but I did find an article that posted “in 2012, Medicare paid $496 million for chiropractic treatments in all 50 states.” (Salzberg, 2014) So if we were to calculate this as 47 percent matching the amount found to be overpaid back in 2006, we are talking about $233 million. Keep in mind, these numbers are only for Medicare claims, this does not include private payors, or their medical necessity guidelines.

Documentation and Templates

When auditing chiropractic services, coders such as myself, come across medical record submissions that contain templates as mentioned earlier. These templates often do not include necessary information to substantiate billing for chiropractic manipulative treatments (CMT) and modalities. Documentation necessary for CMTs includes the precise level(s) of subluxation(s) must be specified for each spinal region manipulated, even down to the precise level or list of exact bones if it applies to only certain bones, ie. (C5,C6) Area/Region.

• The provider should use terms that are clearly understood to refer to bone/joint space or position.
• Documentation of subsequent visits should include linking today’s service to the treatment plan that was established, measuring progress towards goals, changes since last visit, exam, evaluation, and a discharge when no further progress is notable or foreseeable.
• When coding for modalities, time, location, and whether or not it is supervised are key components in substantiating CPT codes. Sample templates can be found on a variety of websites, both for purchase and for free. Unfortunately some of the templates available for use do not include enough information to substantiate billing for chiropractic services. A few examples of commonly used templates can be found below.

What should documentation look like? Documentation should contain information about the patient, including why they were there and what services were provided to them. Many of the modalities are time based codes, therefore documentation of the time spent performing the service(s) is required.

Separately Identifiable Services

What substantiates the need for evaluation or CMT in addition to treatment in the same visit? Chiropractic Manipulative Treatment or CMT includes evaluation and management of the patient regarding the areas being treated. CPT states a 25 modifier can be appended to E/M services when another service provided on the same date is separately identifiable. The AMA’s CPT manual explains separately identifiable as, “the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.” This might mean a different body area, for example, the E/M visit was for the cervical neck area, and the other treatments were for low back, or this might mean the complete and total evaluation of a new patient prior to the decision for treatments being started that same day. Note some carriers allow a 30 day re-evaluation, in which the E/M service is billable. Confirm carrier policy for separately identifiable E/M coverage.

In conclusion, chiropractic services as well as coding and billing of them can be quite comprehensive and confusing. Documentation is key in properly substantiating the services that are being performed. Know the rules, and know your payers medical necessity guidelines to be sure that you are not putting your practice at risk.

Works Cited

1. General, O. o. (2009, May). Inappropriate Medicare Payments for Chiropractic Services. Retrieved June 4, 2015, from OIGHHS.GOV
2. Salzberg, S. (2014, April 20). Forbes, New Medicare Data Reveal Startling $496 Million Wasted On Chiropractors. Retrieved June 4, 2015, from Forbes