Optimize patient care with an adjunctive rehab program, and learn how to code and bill for these services

In a 2000 survey,¹ 98% of responding chiropractors reported using “corrective and/or therapeutic exercise” as an adjunctive care program for musculoskeletal conditions. In addition, more than 60% of their patients received exercise recommendations. Many chiropractors who recommend rehabilitative therapy do so even though they do not receive payment for this additional service.

Most chiropractic practices could generate appropriate rehab services from the same number of patients with just a few procedural changes. In most states (New York being one exception) chiropractic scopes of practice and insurance regulations permit licensed doctors of chiropractic to perform, bill, and be paid for rehab services to their patients. Chiropractic rehab is limited to spinal exercises in some areas, so it is important to know your individual state’s practice laws, worker’s compensation procedures, and insurance regulations.

Candidates for Rehab
When is rehabilitative care appropriate? It is my opinion that many chiropractic patients—whether involved in subacute care or long-term wellness programs—could benefit from specific exercise programs. The sooner patients are started on appropriate corrective exercises, the quicker many respond to their adjustments, and the more satisfied they will be.

For example, athletes with direct-trauma or overuse sports injuries, who wish to return to their athletic activities or improve performance, need instruction on proper strengthening and stretching techniques. Anyone who has suffered an on-the-job injury, or has been injured in an auto accident, will need exercise guidance to regain function, prevent weakness, and avoid reinjury. Patients with an interest in wellness can benefit from spinal fitness exercises along with specific encouragement to stay active, while using correct body mechanics.

Rehabilitative services work best when the system is organized, standardized, well documented, and properly billed (using appropriate codes). Only after these procedures have been implemented can payment be expected.

The standard procedure for most patients is a supervised session in the office with daily in-home exercise sessions between office visits. This method provides for regular supervision while keeping costs and office time down. As improvement and performance are demonstrated, the patient’s in-office frequency can be reduced. Most patients can receive excellent rehab care with supervised sessions for 3–4 months, which is considered reasonable. Auto accidents and work injuries may initially require more frequent sessions since supervision of exercises is more critical in patients with recent back and/or neck injuries.

When preparing rehab documentation, it is important to document the rehab as well as adjustment notes. Because rehab services generally are billed as a separate professional service, the documentation must stand out as an additional procedure. Since rehab programs are active, not passive, it is a matter of recording what the patient did.

The patient must perform the rehab exercises while the doctor instructs, oversees, and corrects the biomechanics. Also, since the codes for rehab services are based on 15-minute intervals, it must be shown that 8 to 22 minutes of direct supervision occurred. There are no billing codes for unsupervised exercising; therefore, the documentation must provide evidence of supervisory involvement by the doctor.

Crack the Codes
There are three commonly used current procedural terminology (CPT)² codes for the level of rehab services discussed here. They are all based on the 15-minute, direct-contact model. While these definitions overlap somewhat, some distinctions can be made:

• CPT 97110 Therapeutic exercise. This is the broadest, least controversial code. Because it is also the easiest code to use, it may be implemented first in many cases. Reimbursement can vary considerably among plans and different state regulations.

• CPT 97112 Neuromuscular reeducation. The definition for this code includes “improving proprioception, coordination, balance, and posture.” It is appropriate to bill for spinal stabilization, posture-changing and wobble-board exercises with this code. Since the exercises covered by this code are more specialized, it is often reimbursed a bit higher. However, be advised that because this code has often been misused to bill for other adjunctive procedures, it is often called into question by insurance companies.

• CPT 97530 Therapeutic activities. This code is defined as “dynamic activities to improve functional performance.” It is a more complex procedure than the other two, and is usually paid at a higher rate. Expert knowledge and skills are needed with this code, which means it often requires more in-depth documentation. It is important to state what function and/or performance is being improved during this session.

When one of these services is provided on the same day as an adjustment, the code should simply be listed in addition to the chiropractic manipulation treatment (CMT) code. If other procedures and/or physical modalities are also being billed on that visit, the rehab session may exceed an insurance plan’s limit of daily charges.

A minimum of rehab equipment or additional space is needed when an office adopts the low-tech approach to rehabilitative exercise. Since patients perform their assigned exercises at home, the instructional rehab sessions can often be done in the chiropractor’s adjusting room or examination room.

Installation of a wall-mounted, professional multi-exercise unit in one or several rooms is a cost- and space-efficient method of preparation. The patient can learn to do the exercises in the office using elastic tubing, therapeutic ball, neck devices and leave with a similar version for at-home exercise. The cost of the home exercise equipment is much less than the fee for doing supervised exercises on a machine. In addition, the patient can do the exercises when convenient, and even take the equipment along on travels.

Billing for the home exercise equipment is usually by CPT 99070 (supplies and materials), although some insurance companies will require a more specific HCPCS code.³ CP

Kim D. Christensen, DC, DACRB, CCSP, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is a team doctor to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, president of the ACA Rehab Council, and a lecturer and the author of many musculoskeletal rehabilitation and nutrition texts. He can be reached at PeaceHealth Hospital via email:kchristensen@peacehealth.org.  

References
1. Christensen MG, ed. Job Analysis of Chiropractic: A Project Report, Survey Analysis and Summary of the Practice of Chiropractic Within the United States. Greeley, Colo: National Board of Chiropractic Examiners; 2001:131.
2. Leavitt DH, ed. ChiroCode Deskbook. 11th ed. Phoenix, Ariz: ChiroCode Institute; 2002:ii.
3. Leavitt DH, ed. ChiroCode Deskbook. 11th ed. Phoenix, Ariz: ChiroCode Institute; 2002:C103.