Following these documentation requirements for manipulation and physical therapy services can help save headaches later

The first part of this article, which appeared in February 2006, discussed the fact that many chiropractic offices are weak in documenting the key points of medical necessity and clinical rationale. The article covered coding and documentation for evaluation and management services.

This follow-up article will discuss the proper documentation requirements for manipulation and common physical therapy services.

CMT Codes
Chiropractic manipulative treatment (CMT) codes include a premanipulation assessment and various adjusting techniques. CMT codes are divided into two sections: spinal and extra spinal regions. The five spinal regions are: cervical, (including the atlanto-occipital joint), thoracic (including the costovertebral and costotransverse joints), lumbar, sacral, and pelvic (sacroiliac joint). There are three levels of CPT coding. Coding is based on the number of regions requiring manipulation justified by the number of regions diagnosed with structural aliments. A provider may choose to “adjust full-spine,” but the coding level is contingent on the patient’s diagnosis.

The “extra spinal” codes also include five regions: head (including the temporomandibular joint, excluding atlanto-occipital), the lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral), and the abdomen. While five regions are listed as extra spinal, there is only one CPT code to use. By definition, the code 98943 is for “one or more” regions. Therefore, when two or more of the extra spinal regions are adjusted on the same visit, only one 98943 may be billed. If an extra spinal region is billed on the same visit as one of the spinal regions, a modifier, –51, must be added to the 98943 code.

For CMT of the spine and CMT extra spinal (98943), if a patient had both a cervical injury and a shoulder injury, manipulation to the c-spine would be billed under 98940, while adjustment of the shoulder is billed under 98943 (extra spinal). A modifier of –51 would be used after the 98943 code to show multiple procedures (two manipulation codes). If an extra spinal area was adjusted without a spinal adjustment, no modifier is necessary. Always use the modifier after the 98943 code, not after a primary spinal code. The carrier may deduct up to 50% from the cost of the second procedure.

Preservices and Postservices
CMT codes include the “usual” preservice and postservice work associated with the procedure.

Preservices include a review of previously gathered data. (such services can include initial complaint, history, exam and test findings, treatment plan, and the patient’s response to treatment).

Intraservices are the inherent assessment of the patient prior to adjustment, such as current status, indications/contraindications, changes since last treatment, evaluating newly developed complaints, mechanical assessment, correlating physical findings, diagnosis evaluation, and coordinating and modifying current treatment plan. Intraservices also include the actual procedure of the adjusting techniques and informing the patient of preeffects and posteffects of the treatment and self care.

Postservices consist of charting and documenting SOAP notes, communicating with other health care providers, coordinating referrals to other health care providers, scheduling tests, updating diagnosis and treatment schedules, and reviewing appropriate literature when necessary.

CMT and E/M
Many insurance companies want to “bundle” or global-fee the Evaluation and Management service with all treatment done on the same visit, especially manipulation. However, as the CPT code book clearly states: “Any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of initial or subsequent “E/M Services” should be reported separately.” This includes the service of manipulation. Just prior to the CMT codes is another indication that CMT and E/M should not be bundled:

The chiropractic manipulative treatment codes include a pre-manipulative patient assessment. Additional Evaluation and Management services may be reported separately using the modifier ‘–25,’ if the patient’s condition requires a significant separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with the procedure. The E/M service may be caused or prompted by the same symptoms or condition for which the CMT service was provided. As such, different diagnoses are not required for the reporting of the CMT and E/M service on the same date.
—AMA, CPT manual (Note: the –25 goes after the E/M code, not the CMT code.)

CMT and Manual Therapy (97140)
If a patient has two separate “regions” diagnosed, (neck and shoulder), and an adjustment was done on the neck (98940) and mobilization was done on the shoulder (97140), a modifier of –59 would be appropriate after the 97140 code, to show distinct different services.

Most carriers will not pay for a 989 code and 97140 if both services are performed in the same anatomical region. (The spine is considered one region, five areas.) A separate anatomical region must be diagnosed to link to the 97140 code. If the 97140 code is being billed as “myofascial release” with an adjustment code, a 98940 and a 97140–59 may be appropriate as long as the 97140–59 code is linked to a muscle diagnosis and the 98940 code is linked to a structural/joint diagnosis.

CMT and CCI Edits
Physical therapy services described by CPT codes 97112, 97124, and 97140 are not separately reportable when performed in a spinal region undergoing CMT. If these physical therapy services are performed in a different anatomical region, the provider is eligible to report these physical therapy codes using the –59 modifier.

If a modality is used as part of the preadjustment treatment (such as hot packs to “loosen muscles and prepare the patient for the adjustment”), that service would be considered as “intraservice” and not “medically necessary” for physiological changes. So, hot packs (97010) would not be billed separately.

PMR Codes (97010 to 97545)
Probably nowhere are there more coding errors than in physical medicine. While some states limit the coding of physical medicine (based on scope of practice), many DCs have the use of the complete list of codes from modalities to activities.

Physical medicine and rehab (PMR) codes are divided into three sections:
1) modalities (supervised and constant attendance) [97010 to 97039];
2) procedures (97110 to 97150); and
3) training and activities (97504 to 97546). Note: the 97110 to 97546 codes are all listed under the heading of “Therapeutic Procedures” in CPT coding manuals; however, the division is in rationale as opposed to strict coding policy.

In coding for PMR, the most important rule is to differentiate rationale based on clinical findings, diagnosis, and phase of care. For example, a new injury case may require a period of care to calm down trauma, reduce edema, and relieve pain (phase one of care). Modalities normally achieve this objective. Modalities would be services such as ice, interferential, and ultrasound. These treatments are considered to have a stand-alone shelf life of only about 2 weeks. If the patient has not progressed to phase two within 14 days, more testing may need to be done, or a report might need to be written explaining why the patient is slow to progress. The 2-week rule is arbitrary depending on many factors. Some patients may respond more quickly; some may take longer. Of course, the longer a patient takes to respond, the more documentation of clinical rationale for medically necessity of the continued course of care will be required.

Once the patient moves into the second phase of care, the objectives of therapy most likely change. While still reducing symptoms, the primary goal is to improve function and minimize deconditioning. Ice, stim, and ultrasound lose their effectiveness, and procedures such as therapeutic exercises, neuromuscular re-education, massage, and manual therapy become beneficial for full recovery. Hence, a new treatment plan may be made to incorporate these therapies into the patient’s schedule. All of the initial therapies may be suspended, or some may be used in conjunction with the procedures. For example, hot packs (97010) may be used as a vasodilator to increase vascular and lymphatic circulation into the muscle prior to performing therapeutic exercises (97110).

All of the 971 codes do require one-on-one patient contact, and are billed in 15-minute increments.

During the third stage of care, after the patient is out of pain and improvement of function is stabilized, he or she may be moved into a rehabilitation mode or work-hardening/work-conditioning mode. Depending on the clinic’s ability to deliver these services, coding is normally selected from the 97535 and higher codes. These services require more clinical skill and are billed in timed units. Documentation must indicate specific goals and objectives. In work-hardening and work-conditioning programs, simulated work duties must be performed. It may be considered inappropriate to use these codes (primarily used for strength and endurance) in phase one of care while still using modalities to reduce pain. However, some modality codes may still be used in conjunction with activities, such as ice used after therapeutic activities. Make sure the documentation does not say the ice is used for pain or inflammation, which would than make the activities code inappropriate.

As long as the treatment plan uses sound clinical rationale and has a logical protocol when billing PMR codes, tying the therapy to the patient’s diagnosis and stage of care, medical-necessity denials should not be a problem. CP

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. Contact her at naca_csoyring@yahoo.com.