Dr. Larry Bridges, Executive Director

Can chiropractors bill for consultation services and if so, when is it appropriate to bill these codes?  Consultation codes are a special category of the Evaluation and Management (E&M) codes.  As we already know, Medicare only covers the spinal manipulation codes for chiropractic but now they have also stopped paying for consultation codes for all healthcare providers. However, most commercial payers continue to pay for consultations, but there are specific rules regarding when you can bill a patient’s insurance company for these services. Let’s look at the facts….

Consultation Definition

The Current Procedural Terminology (CPT) manual defines a consultation as a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

To Bill or Not to Bill

It’s important to note the statement “at the request of another physician or appropriate source” in the definition. This means that you can’t bill for a consultation simply because your patient asked you to consult with them about chiropractic care.  In fact, CPT is clear when it explains that “a ‘consultation’ initiated by a patient and/or family, and not requested by a physician or other appropriate source is not reported using the consultation codes, but may be reported using the office visit codes.” A patient requesting that you render a second opinion or provide a consultation does not meet the CPT definition of a consultation code.

What is an “appropriate source?”

The consultation must be requested of you by a physician (MD, DO, DC, DPM), physician assistant, nurse practitioner, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, or insurance company.

Consultation Codes

In the office setting, the physician should use the appropriate office or other outpatient consultation codes.  These codes are 99241-99245 and are billed based upon the 3 key components, much like office visit E & M codes.  If after the consultation, you defer the patient back to the original source, you can bill for the consultation code if all the criteria have been met.  If the criteria for a consultation code are not met, do not bill for a consultation.  Instead select the appropriate office visit E & M.  If you take over the care of the patient, then you can bill for any subsequent treatment performed.

You Must Document!

Before a consultation takes place, there must be a written or verbal request made by the requesting physician or other appropriate source. The request and reason for the consultation must be documented in the patient’s record. The consultant’s opinion and any services that were ordered or performed must also be documented in the medical record and communicated by written report to the requesting source.  Here’s a tip: Remember the three R’s: Request, Render, and Respond.

What about Referrals?

A referral is NOT a request for a consultation but rather is a transfer of total care or a specific portion of care of a patient from one physician to another.  If a referral occurs that does not meet the criteria for a consultation, use the appropriate outpatient office visit E & M codes for either a new or established patient.

Summary

There are instances in which a chiropractor can bill for a consultation.  Just remember that a written or verbal request must have been made from an appropriate source.  As the consultant, you must perform a history and exam and render an opinion or recommendation.  And finally, your opinion as the consultant must be sent back in writing to the requesting source.  All of this must be documented in the patient record.  Any procedure performed on or subsequent to the date of initial consultation is reported separately.  A consultation initiated by the patient or the patient’s family is not a billable consultation but rather is billed with an office visit E & M code.  If after the consultation, you assume responsibility for managing all or a portion of the patient’s condition(s), then you can also bill for the procedures you performed.

Recently, a local chiropractic clinic called our office seeking guidance on how to code and bill for certain stretches and exercises. The doctor had been incorporating these into patient treatment plans for years, yet he was not getting reimbursed for these services. They simply didn’t know what codes to use for what therapies. Because we get this question regularly regarding the proper coding of active therapies in the chiropractic office, we decided to make it a blog topic in case there are other offices struggling with this. There seems to be a lot of confusion surrounding the codes 97110, 97530, and 97112 specifically, and rightly so since it can be difficult to determine the difference in these three codes by reading the definition alone.  Hopefully this article will help eliminate the ongoing confusion regarding active therapy billing. 

First of all, let’s address the definition of “active” care and how it is different from passive therapies.  Like the office we assisted, you may be providing active care in your office already and not even billing for it.  Active therapy is a type of care in which the patient is actively engaged in some type of physical therapy that is directed by the doctor or therapist and  requires a responsibility on the part of the patient to participate.  This could be in the form of stretching, aerobic activity, strengthening exercises, balance to improve proprioception, some type of procedure to increase range of motion, or any number of other activities.  The key is that the patient is performing the therapy rather than having the therapy performed on them.  During passive therapy, however, the patient is taking no active part in the procedure. Examples of therapies that are passive are ultrasound-97035; traction-97012, electrical muscle stimulation-97014 or 97032; and heat/ice-97010.

When choosing a code to bill for an active therapy, you should look at not only the service or type of therapy done, but also the intended therapeutic outcome or what you hope to improve in the patient.  Ask yourself, “Am I applying this service to simply improve joint mobility or strength or am I attempting to restore a specific function in the patient? Will this service be addressing one parameter only or multiple parameters?” 

Let’s take a look at active therapies that may be used in the chiropractic setting, keeping in mind that these three services are all timed therapies which means they are billed in “units” according to how much time is spent performing the therapy, not how many anatomical areas are treated.

97110    Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility¹.

The CPT® Assistant Archives give further clarification to the definition above. Therapeutic exercise incorporates one parameter (strength, endurance, range of motion or flexibility) to one or more areas of the body. Examples include treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility), and gymnastic ball (for stretching or strengthening)².

97530    Therapeutic activities direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes ¹.

Additional information from CPT® Assistant further explains that dynamic activities include the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity. Examples include lifting stations, closed kinetic chain activity, hand assembly activity, transfers (chair to bed, lying to sitting, etc.), and throwing, catching, or swinging².

97112    Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities¹.

97112 is perhaps one of the most misused and misunderstood of all the active therapy codes.  Many times providers will use this code for certain types of massage or soft tissue therapy, and that is not what this was intended for.  Examples of services that may be performed to rehabilitate the patient’s neuromuscular issues include Proprioceptive Neuromuscular Facilitation (PNF), Feldenkreis, Bobath, BAP’S Boards, and desensitization techniques².

As with all procedures, there is a professional component of one on one time with a patient.  The CPT® definition specifically states “Physician or therapist required to have direct (one on one) patient contact.”  If the provider does a group therapy session, then the service should be billed as a 97150 regardless of the procedure.

There are many other active therapy codes in the physical therapy section of the CPT® code book, but these three are the most frequently used by chiropractors due to the nature of the physical therapy they provide and seem to be the ones we get the most questions about.  So in summary, 97110 is used when affecting one parameter (strength, flexibility, ROM), 97530 is for multiple parameters and to improve a functional activity, and 97112 is for reeducating or re-patterning the motor system in some way or for when there has been a loss of coordination.

For more information, refer to current CPT® coding materials and guidelines.

This is an example only and may or may not reflect a real situation, but in a scenario where a commercial payer adopted the MPPR policy and used the above allowable fees, 97110 would be paid at $28.43 (100% of the allowable). 97140 (which has the lower practice expense) would be reduced to $24.31. That is 80% of the PE portion (.38 * 80% = .304) + .43 + .01 * DCF = $24.31.

Impact:

For those of you who perform multiple units of a therapy and/or multiple therapies at the same session, you could see payment for your additional units and therapy procedures reduced if payers begin to implement this Medicare policy as part of their reimbursement.  As of this publication, Aetna is currently using the MPPR policy and UnitedHealthcare will begin using it March 1, 2012.

RESOURCES:

Medicare MLN Matters Article: MPPR for Selected Therapies

Aetna Office Link Update

The International Classification of Diseases, 10^th Edition Clinical Modification (ICD-10-CM) is based on the ICD-10 diagnostic coding system that was developed by the World Health Organization (WHO) in 1993 to replace ICD-9 that has been around since the 70’s.  Currently, the United States is one of the last remaining industrial nations that have not fully implemented ICD-10 code sets.  The ICD-9 system is outdated and can no longer grow or expand to reflect the advances in medical data and knowledge about conditions and symptoms.  In other words, medical science continues to make new discoveries and add to the descriptions of illnesses, but there are no numbers to assign to these diagnoses. ICD-9 has reached its capacity of 14,000 codes.  ICD-10-CM however, will reach approximately 68,000.  (That doesn’t include the new ICD-10-PCS for inpatient hospital procedure reporting.) In addition, ICD-10-CM will allow the US to better maintain clinical data and compare it with the rest of the world. This will improve global data sharing that is critical for public health, comparing costs and outcomes of medical technology, and collecting disease and mortality data. What this means for healthcare providers is that the way they report and document patient symptoms, conditions, clinical history, and external causes is going to require much more specificity than what is required by the ICD-9 code set.

While we are still a little over 2 years away from the go-live date for ICD-10 implementation, it’s important to start planning for this transition now.  Hospitals, doctors’ offices, medical centers, and health plans are required to start using the new ICD-10-CM coding system on October 1, 2013.  CMS has made it clear that there will be no grace periods or implementation delays.  With that said, it’s important to keep in mind that it‘s still a little too early for ICD-10 code set training.  It’s impossible for doctors and staff to remember for two years codes that they don’t use every day.  In fact, the codes and guidelines that you learn now may not be in the final draft that will be available in 2012.  Instead, in these early stages, it’s important to gain an overall understanding of several key areas and ask yourself how this will affect your practice.

What will ICD-10 look like and how will ICD-9 translate into ICD-10?

While ICD-9 codes are 3 to 5 digits long, ICD-10 codes may be up to 7 digits and will always start with an alpha character. Characters 1-3 describe the category. Characters 4, 5, and 6 specify etiology, anatomic site, & severity or other clinical data.  Character 7 is an extension for descriptors such as initial encounter, subsequent encounter, or sequela.  There is a General Equivalence Mapping (GEM) tool that assists with understanding the conversion of ICD-9 codes to ICD-10 codes.  Some ICD-9 codes translate easily to ICD-10 in what’s called a one-to-one conversion.  But in other cases, there is no mirror image of an ICD-9 and ICD-10 code.  There may be a multitude of different mapping ratio relationships such as one-to-three, one-to-twelve, or even one-to-2,500.  Consider sciatica for example (ICD-9 code 724.3).  In the ICD-10 set there is a code for sciatica unspecified, sciatica right side, sciatic left side, lumbago with sciatica unspecified, lumbago with sciatica right side, and lumbago with sciatica left side, plus codes that describe sciatica due to intervertebral disc disorder.

How will the new system affect my administrative processes?

Your office’s administrative area will be impacted in several ways. In addition to the obvious coding and billing changes, superbills and forms may need to be updated and your information technology will need to be assessed.  Practice management software will need to be updated for the new code set. Practices may need to run dual systems during this transition, meaning you will need to have the capability to bill ICD-9 codes for dates of service prior to 10/01/13 and in case some health plans aren’t ready to accept ICD-10.  Now is a good time to talk to your business partners such as your practice management software vendor and clearinghouse to make sure that your billing processes will be updated and ready for testing and/or receiving ICD-10 data before the go-live date.  In fact, the preparation for ICD-10 also brings with it a change in the area of submitting electronic claims in the new HIPAA 5010 version.  The deadline for transitioning to HIPAA 5010 transactions is January 1, 2012.  You will need to either update your practice software or discuss translation with your clearinghouse. Regardless, it is imperative that your software be ready for ICD-10 before October 2013.

How will ICD-10 impact my clinical processes and reimbursement?

Currently reimbursement is tied to procedure codes, and it’s the diagnosis codes that support medical necessity. However, local coverage determinations and medical policies will be revised to include the new code set.  Even though the ICD-10 conversion is not intended to alter reimbursement, a change in medical policies could result in a change in reimbursement methods.  Perhaps the biggest impact to your clinical processes will be in the area of documentation.  As we get closer to the go-live date, the term Clinical Documentation Improvement (CDI) will be used more frequently. CDI refers to ensuring that your documentation is detailed enough so that the proper ICD-10 code can be selected.

How can I assess the specificity of my documentation to determine if I’m ready for the expanded ICD-10-CM Code descriptions?

It’s important to remember that the diagnosis code should be selected based on your documentation of the patient’s condition and symptoms, not the other way around.  You can begin to audit and assess your documentation now to see if there are weaknesses in this area.  The increased specificity of ICD-10 codes will require you to attain and document as many details from your patients and your exam findings as possible.  Start by running a report and determining the most frequent ICD-9 codes you currently use. Start with the top diagnosis seen in your office and pull about 5 or 10 files of patients who have that specific diagnosis.  Go through the documentation and test yourself.  Determine if you described everything needed to select that ICD-9 code. Then look up what that code might translate to in ICD-10. Determine if your current documentation would support a more specific ICD-10 code. For example, if sciatica is a common occurrence in your patients, check your documentation to see how specifically you are describing sciatica in your notes.  Ask yourself if your notes are descriptive and detailed enough to meet ICD-10 standards.

Stay educated and informed about the implementation of ICD-10. To help you, we have included some resources below that you can use to stay updated on ICD-10 implementation.

More information & References:

ICD-10 Code Translator: http://www.aapc.com/ICD-10/codes/index.aspx

ICD-9 to ICD-10 Conversion & Mapping Tutorial: http://www.aapc.com/ICD-10/conversion-mapping.aspx

ICD-10 Provider Office Changes: http://www.aapc.com/ICD-10/office-map/index.aspx

About ICD-10 & ICD-10 FAQ’s: http://www.ahima.org/icd10/about.aspx

About General Equivalence Mapping (GEMs):

http://library.ahima.org/xpedio/groups/public/documents/government/bok1_043820.pdf

https://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp