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Billing for manipulations

This section covers how to bill for spinal and extra-spinal manipulations.

Benefits 

Priority Health offers many different types of benefit plans. Some include the manipulation benefit under short-term rehabilitative coverage, which means all services, including physical and occupational therapy, biofeedback and manipulation, count to the same benefit limit.
  • Before treatment, verify if a patient has exhausted his/her short-term rehabilitative benefits by calling the Provider Help Line.
  • Benefits renew annually on the patient's contract renewal date, which may or may not be January 1.
  • Also see the section on Billing for physical therapy in this manual.

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Abbreviations

Priority Health accepts standard abbreviations. If your office uses unique abbreviations, you should have a standard abbreviation sheet that everyone in your office uses in the same manner and that can be supplied to Priority Health with your documentation.

Documentation guidelines

Documentation must stand alone for each date of service. Providers may use their own formats for documenting services. However, documentation must support the services billed for each date of service.

All documentation must:

  • Be legible.
  • Include the member/patient's name and date of service on EACH PAGE of the medical record.
  • Include as appropriate: relevant history, examination and treatment including method utilized (CS – counter strain, IND - indirect, etc.).
  • Indicate the number of areas treated, location of treatment (lumbar spine, ribs, etc.) and how the patient tolerated the service. Documentation stating "treatment tol well" or "continued as above" is not acceptable medical record documentation reimbursable by Priority Health.
  • Match the plan of care/treatment
  • Support the medical necessity of each treatment/modality/procedure.
  • Indicate improvement or lack of improvement in patient function. This should be determined by the physician and may require further intervention and change of treatment plan. If treatment continues for an extended period of time without changes to patient's status, documentation should indicate response to and changes in treatment or need to continue with same program.

Corrections and signatures

  • Documentation corrections should be made by a single line drawn through the error, with the corrected text and date of correction added in close proximity, initialed by the person who made the error.
  • All documentation provided by a qualified health care professional should include a written or electronic signature, initials, and/or a stamp of original signature.

Radiology

Only one provider should bill for a written interpretation of the x-ray. If you are only reviewing what the radiologist or other physician has interpreted, do not bill for this service.

Using modifiers

  • If a provider does both the technical and professional components of a procedure, the procedure code should be billed without a modifier to show it is a global service. 
  • TC modifier: If the x-rays are taken in the office and interpreted by another provider outside your practice, append the modifier -TC (technical component) to the procedure code. 
  • 26 modifier: If the x-rays are taken by another provider and you provide the written interpretation, append the modifier -26 (professional component) to the procedure code. 

Chiropractic manipulative treatment

Priority Health follows national standards for documentation and billing of these services. Reference the documentation guidelines above.

Chiropractic treatment codes include a pre-manipulation patient assessment.  Priority Health recognizes that an additional evaluation and management service may be needed if the patient's condition requires a significant separately identifiable E/M service above and beyond the usual pre- and post-service work associated with the chiropractic service.  The medical record documentation needs to support all procedure codes billed.

The American Chiropractic Association states, in article titled "Coding Misuse Prompts Fraud Investigations":
Billing an Evaluation and Management (E/M) Code on Every Visit with CMT: In general, it is inappropriate to bill an established office/outpatient E/M code (99211-99215) on the same visit as Chiropractic Manipulative Treatment (98940-98943) because CMT codes already include a brief pre-manipulation assessment. There are times when it would be appropriate, but it should not be routine. Examples of when it may be appropriate to bill an additional E/M service would be the evaluation of new patients, new injuries, exacerbations, or periodic re-evaluations. If you are being told that billing an E/M code on every visit is a proper form of billing, it is incorrect. Please refer to the American Chiropractic Association (ACA) website www.acatoday.com, Insurance and Reimbursement, for specific guidance on the proper use of E/M with a Chiropractic Manipulative Treatment Code (CMT).
References

Osteopathic services

Priority Health follows national standards for documentation and billing osteopathic manipulative treatment services.
  • E/M services may be reported separately, using modifier 25 if the patient's condition requires a significant separately identifiable E/M service above and beyond the usual pre- and post-treatment service.
  • The E/M service may be for the same conditions for which the OMT is provided, so it may be billed with the same diagnosis.
  • The documentation should clearly distinguish the services that support the E/M service and the OMT service. 
  • E/M service is not warranted for planned follow-up treatments unless the patient presents with a new condition, change or lack of improvement in condition that necessitates an overall reassessment.
  • Billing must be supported by the documentation requirements in this section of the Provider Manual.

References
Last modified 03/25/08