November 29, 2018 by Kathy Mills Chang, MCS-P, CCPC, CCCA Article Insurance, Billing, Coding
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Selecting Medicare billing codes may be one of the simplest tasks we have, because there are only three spinal chiropractic manipulative treatment (CMT) codes that are covered under Medicare. However, our audits reveal significant errors. Most revolve around these three services: physical medicine CPT codes 97014, electrical muscle stimulation, 97010, hot/cold packs and the spinal CMT codes 98940-98942. Since Medicare is required to use CPT coding guidelines, why is the CPT code 97014 denied when billed to Medicare, for example? And why all the additional confusion?

Is it CPT 97014 or G0283?

Medicare may substitute a different level code, such as a Healthcare Common Procedure Coding System (HCPCS) code, when it decides that such a code is more descriptive and meets Medicare requirements. For example, a March 2003 Communiqué reads, “On March 1, 2003 the procedure code 97014 electrical stimulation (unattended) (EMS) became status I, ‘Not valid for Medicare purposes.’ Medicare then chose three HCPCS codes in 2003 for electrical stimulation (unattended):

G0281 and G0282 – These codes would be used for wound care treatment and therefore not appropriate for the chiropractic office.

G0283 – Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.”1

When submitting EMS to Medicare, you must use G0283 to receive the proper denial if you need to bill a secondary payer. The rules also state to append the modifier GY and possibly GP (if your Medicare carrier requires this) to receive a proper denial that the secondary will consider. G0283 is the preferred Medicare billing code for EMS, but it may not be accepted by other carriers. For example, United Health Care requires the same G0283 instead of 97014. Modify your practice systems to use G0283 only for submission of electrical muscle stimulation treatment to Medicare and the CPT code 97014 to other carriers, unless carrier direction states otherwise.

Hot or Cold Packs: I did it, so don’t I have to bill it?

CPT Code 97010 is a misunderstood Medicare billing code. It’s often overbilled throughout healthcare because it is difficult to establish appropriate rationale to prove medical necessity for this to be separately billed in the office. The American Chiropractic Association (ACA) has published this guidance for the proper use of the service:

“It is the position of the American Chiropractic Association that the work of hot/cold packs as described by CPT code 97010 is not included in the CMT codes 98940-43 in instances when moist heat or cryotherapy is medically necessary to achieve a specific physiological effect that is thought to be beneficial to the patient.

Indications for the application of moist heat include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation and increase in lymph flow to the area. Indications for the application of cryotherapy include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation and increase of lymph flow to the area.”

For this reason, be sure that any written treatment plan includes the necessary rationale for prescribing hot/cold packs and that you understand the guidelines for the efficacy of using this service along with other physiotherapeutic modalities, beyond the first several visits of an episode of care.

Medicare considers CPT Code 97010 (hot/cold packs) a ‘bundled’ service. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. In this instance, it means 97010 is not a separately payable Medicare billing code. When Medicare is the primary payer and you submit 97010-GY along with covered CMT codes 98940-98942, the 97010 service will be denied with the remark code M15: Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

The hot/cold pack is considered a part of whatever primary service is rendered to the patient, and in the case of chiropractic, that is a CMT code. (98940-98942). Remember, this is different than a ‘non-covered’ or ‘excluded’ service, which must be charged to the patient. A bundled service can never be separately charged to the patient, as it is being reimbursed within another code’s value, such as the CMT.

Which CMT Code is Correct?

Selecting the proper CMT code for the number of regions treated should be simple. Medicare billing code 98940 represents 1-2 spinal regions, 98941 represents 3-4, and 98942 represents all 5. Straightforward, right? Not so fast! Medicare, and most third-party payers expect that when a spinal region’s adjustment is presented for reimbursement, the documentation will reflect all the necessary components, including medical necessity. This usually means there has been a complaint in the region, documented in the history of the initial visit. Then, there are exam findings to support that, leading to a diagnosis of M99.X (the proper Medicare billing code set in ICD-10 for subluxation) That diagnosis is supported by a secondary, neuromusculoskeletal diagnosis code representing the condition. And finally, the spinal region is included in the treatment plan. If you consider yourself a full-spine adjuster, and regardless of complaint or findings, adjust all the spinal regions, they must be reported properly. If the non-primary subluxation must be addressed to stabilize the primary subluxation, report the proper CMT code for the medically necessary regions, and then list the compensatory adjustments in the medical record as having been treated. This clarifies why an area may be represented but is not being billed.

Mastery of Medicare billing codes can be tricky. By understanding just a few special rules, however, your billing can fly through, clean as a whistle, and have you paid properly in no time.

About the Author

 

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P). Certified Chiropractic Professional Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 25 at KMC University and is known as one of our profession’s foremost experts on Medicare, documentation and CA development.

Kathy or any of her team members can be reached at (855) 832-6562 or info@KMCUniversity.com

 

Sources:

http://www.cms.gov/Regulations-and-guidance/Guidance/Transmittals/downloads//AB03093.pdf

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