Thanks to Today's Chiropractic for permission to reproduce this article!
By Mark Sanna, D.C.
As simple as it sounds,
if you want to get paid for what you do, you must speak the language of coding.
In order to fully understand coding and reimbursement, and be able to speak
that language, you must understand how the coding system works and how and why
values are set forth for every service you do. By and large, coding is created
for the Medicare system, and thus, many federal directives dictate coding polices
and reimbursement related issues. Providers are frequently underpaid by payers
for services rendered. The cause of this low reimbursement doesn’t always
lie with the payer, however. It may be the result of improper coding and documentation
by the provider. By understanding how the coding process works, we can more
easily develop our coding and fee schedule for our office to assure maximum
reimbursement. Let’s address the three major points your office must be
aware of in order to assure proper reimbursement:
Understanding the CPT
Coding and Resource Based Relative Value System
Properly coding for
the services you render
Assuring your level
of documentation will support the services you rendered.
The CPT Coding system is
updated and published annually by the American Medical Association. Most practitioners
are unaware, however, that this coding process is overseen and approved by the
Department of Health and Human Services. Most coding is developed for Medicare
purposes. For example, when it was determined there was a need for specific
chiropractic manipulative treatment (CMT) codes, the process was begun in 1996.
These codes were created for reimbursement within the Medicare program. The
simple creation of these codes increased Medicare reimbursement for doctors
of chiropractic by more than 50 percent from the old A2000 code. As you know,
the CMT codes are now the primary codes used for average day-to-day encounters
with our patients. The process was begun and adopted for Medicare, but the codes
are widely accepted by most all insurers. The process includes assigning a value
to the codes, known as the Resource Based Relative Value System (RBRVS). This
system assigns three values to each code: a work value, a practice expense value,
and a malpractice value. The application of each of these, when multiplied by
geographic equivalents and a yearly conversion factor, determines the Medicare
reimbursement value for each code. These are the values you receive at the end
of each year from your Medicare carrier to let you know what your fee schedule
will be for the next year. The work value of a code represents the “work
per unit of time” in general, and is based not only on the amount of time
spent with the patient, but also the amount of work, physician skill and judgment
required during the visit. This constitutes the majority of the value of the
code. The second value is known as practice expense. This value fluctuates annually,
and is primarily the reason you may see a few cents increase or decrease in
your Medicare fees on an annual basis. This value includes things such as the
cost of your physical plant, your staff, electricity, supplies, etc. The final
value is a malpractice value. This number is dependent upon the risk of the
The reason all these facts are important is that the Medicare
system drives reimbursement. Although the private payers have their own fee
schedules, one need only to look at the recent flood of denials associated with
the Medicare Correct Coding Initiative (CCI) edits to see how Medicare initiatives
can drive reimbursement within our profession. Although Medicare allows only
the CMT codes to be reimbursed in the program, they have set edit checks coupled
with the CMT codes to deny other services rendered on the same date, such as
massage, manual therapy or neuromuscular reeducation. These are known as mutually
exclusive services. Logic dictates that this should not be an issue since Medicare
does not cover these other ancillary services. However, many private payers
have adopted these edits as the basis for their own, and it has driven a startling
reimbursement trend. More and more payers are inching toward the CMT being the
only covered service for doctors of chiropractic. It is clear to see how this
Medicare coding system can affect our reimbursement in the private payer arena.
More and more payers are adopting the Medicare RBRVS fee system to determine
their reimbursement guidelines. For this reason, it behooves each of us to be
intimately aware of the connections between Medicare and the private payer system,
and to understand how this coding system affects us in our daily practice. It’s
also imperative for us to make sure that the CMT remains a chiropractic service
within Medicare. We should also support the initiatives put forth by our national
associations to assure that all services provided by doctors of chiropractic
are reimbursable under the Medicare program.
The second point that will assist your practice in maximizing its reimbursement
is to assure that all the services you are providing are being correctly billed,
or it might be prudent to say in some cases, are billed at all! So often, when
analyzing practices, it seems that the greatest outpoint is providers providing
services that are never billed or charged to patients. As an illustration, two
major trouble spots are noted most often for incorrectly coding or billing.
These are evaluation and management (E&M) services and extremity adjusting.
Evaluation and Management
codes are wonderful tools to help describe the physician-level services that
doctors of chiropractic perform all the time. DCs are able to utilize these
codes to properly describe the evaluation techniques performed. Too often, denials
appear because certain payers feel these services are not reimbursable on the
same date of service as a CMT code. While it’s true that it is inappropriate
to bill an E&M service every time you perform a CMT, there are many times
it would be appropriate during a patient’s course of treatment in your
office. Some examples of when it is appropriate to bill a separate E&M code
on the same day as a CMT code include a new patient visit, an established patient
with a new condition, new injury, re-injury, aggravation, exacerbation, or a
re-evaluation to determine if a change in treatment plan is necessary. Use of
E&M services should be supported by appropriate documentation. All too often,
doctors of chiropractic fail to recognize when it’s appropriate to additionally
bill an E&M service. In some cases, they have had the E&M service denied
when the CMT is billed the same visit, and choose not to bill them together
any more. However, it is certainly appropriate to bill an E&M service any
time there is a separately identifiable E&M service. Make sure to append
the “25” modifier to the E&M service.
Another service being grossly
under billed is 98943, which is the code for extraspinal CMT. The five extraspinal
regions are head (this includes TMJ), upper extremities, lower extremities,
anterior ribs and stomach. All too often, DCs are providing this service and
failing to appropriately bill. When performed on the same day as a spinal CMT,
it’s appropriate to bill the 98943, together with the “51”
modifier. This indicates to the insurance company that the two codes were done
on the same visit. Additionally, it’s important to properly document the
medical necessity for the extraspinal region. Five points are necessary to help
justify this billing:
A documented patient
Objective findings in
the extraspinal region.
A diagnosis supporting
the treatment of this extraspinal region.
Clinical notes indicating
the treatment of the extraspinal region.
A treatment plan for
that region. It’s also helpful place that diagnosis in the fourth position
in box 21 of the HCFA billing form, and to link the diagnosis in box 24E of
the HCFA when billing 98943-51.
assure that all the services rendered in your office are properly documented
for medical necessity. This is much easier said than done. Particularly in the
Medicare system, improper documentation accounts for more than half of the denials
handed forth by carriers. It’s the physician’s job to properly communicate
in the clinical record, the encounter specific reason for the treatment. These
three points will serve as a litmus test when reviewing your documentation for
accuracy and completeness:
Make sure there is a
response to the adjustment noted in the record, such as increased ROM, increased
function, decreased pain, etc.
The record should reflect
quality, character and intensity that would qualitatively and quantitatively
substantiate the need for care.
There should be a treatment
plan noted in the record with functional goals in place that can be measured,
such as with Oswestry or Roland Morris outcomes assessments.
As you can see, by understanding the coding system and RBRVS reimbursement system,
together with coding and billing correctly for services and carefully documenting
medical necessity in your clinical records, you will take control of your reimbursement
situation. When the services rendered are billed and coded correctly, and the
documentation supporting the services is bulletproof, you will find little to
no resistance to proper reimbursement.
Dr. Mark Sanna is a second-generation chiropractor and the president and CEO of
Breakthrough Coaching. For more information visit mybreakthrough.com.
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