Decoding Manual Therapy:
Unraveling the New Rules for Reimbursement

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

Thanks to Today's Chiropractic for permission to reproduce this article!

Mark Sanna, D.C.

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In 1999 the CPT code 97140, Manual Therapy, replaced three codes: Joint Mobilization, 97260/5; Manual Traction, 97122; and Myofascial Release, 97250. Since that time chiropractors have been frustrated by continually having their claims denied for dates of service on which manual therapy was performed in conjunction with other procedures, including the chiropractic adjustment.

In clinical practice, along with joint mobilization, manual traction, and myofascial release, manual therapy includes other therapies performed by hand. Nimmo technique, or trigger point therapy, and PIR, PNF and other stretching techniques would fall under the heading of manual therapy techniques typically performed in a chiropractic setting. Some practitioners have been unclear about how to appropriately code for Cox and Flexion-Distraction techniques, as it could be inferred that they would fall under the heading of manual traction. The Center for Medicare and Medicaid Services (CMS), the regulatory body for CPT coding, has classified Cox and Flexion-Distraction techniques as chiropractic techniques. They should therefore be coded using the appropriate spinal chiropractic manipulative treatment codes (98940-98942).
As of April 1, 2002, a “bundling virus” in the National Correct Coding Initiative (NCCI) edits was corrected. Now chiropractors must be paid for neuromuscular reeducation (97112), massage (97124), and manual therapy (97140) when “performed on separate anatomic sites or at separate patient encounters on the same date of service as a chiropractic manipulative treatment (98940—98942).” This was perhaps the biggest reimbursement news of the entire year for chiropractors.

Separate Anatomic Sites

According to the NCCI correction, when the same provider performs manual therapy and chiropractic manipulative treatment (a spinal adjustment) during the same office visit, the two procedures must be performed on separate anatomic sites. There are five spinal regions that qualify as separate anatomic sites. These are: the cervical region (includes atlanto-occipital joint), the thoracic region (includes costovertebral and costotransverse joints), the lumbar region, the sacral region and the pelvic (sacroiliac joint) region. In addition, there are five extraspinal regions: the head (including the TMJ, excluding atlanto-occipital region), the lower extremities, the upper extremities, the rib cage (excluding costotransverse and costovertebral joints), and the abdomen.

Item 21: The Diagnosis

CMS 1500 insurance claim forms are printed in red because they are optically scanned. You report numbers on the claim form because you are communicating to a computer, and you must be sure to provide the computer with the right numbers. The diagnosis from the doctor located in Item 21 on the claim form informs the payer about the patient and why they are receiving care.

As previously stated, when performing 97112, 97124, or 97140, with an adjustment, the procedures must not be performed on the same body area. This is indicated on an insurance claim form by linking each procedure performed to a diagnosis referring to a different area. If your billing software automatically defaults to diagnoses 1-4, you should contact your software vendor to learn how to link diagnoses.

Separate Encounter

According to NCCI, manual therapy and a chiropractic adjustment can be performed on the same area when delivered during separate encounters with the same patient. Two definitions of a separate patient encounter have been provided by NCCI. The first definition of a separate encounter is that different providers perform the two procedures on the same date of service. For example, if a massage therapist performed the adjunctive physiotherapy procedure and a chiropractor performed the adjustment, it would qualify as a separate patient encounter. This rule includes only licensed providers, such as chiropractors, physical therapists and massage therapists and does not include chiropractic assistants.

The second definition of a separate encounter is that the same provider performed the two procedures during a second visit on the same date of service. In this case the patient would receive his or her chiropractic adjustment during a visit in the morning, and manual therapy at a second encounter later in the day.

Counting 15-Minute Intervals

In addition to the rules governing who can perform manual therapy and when it can be performed, there is an additional complication. Manual therapy is a timed code, which means that it is counted in units of 15 minutes when performed by a chiropractor. It is important to note that only the “intraservice” care—the time actually spent providing therapy—can be counted and billed. When does intratreatment time start? The time spent greeting a patient and inquiring how a patient’s care is going is when intratreatment time starts, if you are performing a clinical observation during this period of time. When you watch a patient’s gait and how safely the patient negotiates doors, levels, etc., it’s considered billable service time. You must document the observations you made during that time.

Manual Therapy Modifiers

There are two important modifiers that require your attention when performing manual therapy in conjunction with a chiropractic adjustment. First, the codes 97112, 97124 and 97140 require the modifier 59 (distinct procedural service) when performed at the same encounter as a chiropractic adjustment. The 59 modifier instructs the insurance carrier’s software not to “bundle” the two procedures together, resulting in a denial of payment.

When a timed procedure, such as manual therapy is not completed for a complete 15-minute unit, it must be reported as a reduced service. You must add a second modifier, 52, to the Manual Therapy code, 97140, to indicate that a reduced service was performed. If, for example, only 7.5 minutes of Manual Therapy were performed in conjunction with an Adjustment, the proper code to report would be 97140-59-52. You should reduce the price for this procedure by one half of the fee you charge for the full 15-minute session. If only 3.75 minutes were performed, the code would remain the same, and your fee should be reduced to one quarter. You can differentiate the different levels of service by changing the narrative descriptor you use for each procedure, for example, manual therapy: 15 minutes; manual therapy: 7.5 minutes; and manual therapy: 3.75 minutes.

Bundling Virus Losses

With the bundling virus problem solved, chiropractors can now go back and resubmit claims for payment for therapy codes that were previously denied. Remember that effective documentation is the key to reimbursement. Make the appropriate changes to your coding and office procedure for all current and future patients and review previously submitted claims that would comply with the rules outlined above. These rules include the provider performing the service, the encounter in which the service was performed, the areas on which the procedures were performed, appropriately linking diagnoses, and applying the correct modifiers. You can download a letter from CMS outlining the rules for resubmission from the ChiroCode Institute, at chirocode.com.

How far are you able to go back? Is it just to April 1, 2002, or can you go back further? I commend you to go after your fair share. Each state has its own statute of limitation (how far back you can go). It could vary from 2-5 years. For your state law, ask your state association or its NACA legal counsel.

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Dr. Mark Sanna is the CEO of Breakthrough Coaching and the president of Corporate Health of America. He can be contacted at (800) 723-8423, online at info@mybreakthrough.com, or via the company’s web site, mybreakthrough.com.

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