Chiropractic CPT codes are crucial for the insurance billing process. Errors in billing can lead to costly denials and delays, impacting your practice’s financial health.
Coverage for chiropractic services is specifically limited to manual manipulation of the spine to correct a subluxation. A subluxation is defined as a motion segment where the alignment, movement integrity, or physiological function of the spine is altered, while maintaining contact between the joint surfaces.
What is the CPT Code 98940?
One of the critical codes used for manual manipulation of the spine is the 98940 CPT code, which is essential for accurate medical coding for chiropractic manipulative treatment. It is a primary code used to identify CMT services provided to patients.
According to the American Academy of Professional Coders, the 98940 CPT code description is:
“The provider applies manipulation to influence joint and neurophysiological function by a variety of techniques and modalities in one to two spinal regions.”
98940 CPT Code Definition and Areas Treated
| CPT Code | Area/Region(s) Treated | Number of Regions | Documentation Requirements |
| 98940 | Spinal (cervical region, (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joints); lumbar region; sacral region; and pelvic (sacro-iliac joint) region) | One or two | • Pre manipulation assessment (review of imaging, physical examination documentation) • Response/Outcomes to Treatment • Plan for Ongoing Care |
Challenges of Using CPT Code 98940
Using CPT code 98940 can present several challenges for chiropractic practices. Below are expanded details on the most common issues:
1. Documentation Requirements
Accurate and comprehensive documentation is critical for using CPT code 98940. Insurance companies often require detailed records to justify the medical necessity of the treatment.
Insufficient documentation can lead to claim denials. Providers must ensure they consistently include essential information, such as the patient’s history, assessment, treatment plan, and progress notes, which can be time-consuming.
2. Modifier Confusion
Modifiers like AT (Acute Treatment) and GA (Waiver of Liability) are essential for correct billing. Misapplying these modifiers can result in claim denials or delays.
Chiropractors must stay informed about when and how to use these modifiers properly, which can be challenging due to evolving guidelines and payer-specific rules.
3. Insurance Policy Variability
Different insurance companies have varying policies regarding the coverage of chiropractic services. This variability can lead to confusion about what is billable under 98940 code. Practices must regularly review each payer’s policies to ensure compliance, adding complexity to the billing process.
4. Claim Denials
Claim denials can be a significant issue for practices using CPT code 98940. Incomplete or incorrectly submitted claims often require time-consuming appeals and resubmissions. This not only affects cash flow but can also strain administrative resources. A high denial rate can indicate underlying issues with documentation or understanding of coding requirements.
For instance, according to the CMS, some of the reasons for 98940 denials are:
- Services would not be considered medically reasonable and necessary in the absence of pain or symptomatology resulting from a subluxation of the spine.
- Medicare’s coverage for Chiropractic services is limited to manual manipulation of the spine. Any other diagnostic or therapeutic services(s) furnished by a chiropractor or under his or her order will be denied.
- All claims submitted for chiropractic manipulative treatment by specialties other than specialty 35 (Chiropractor) will be denied.
5. Patient Education
Educating patients about their insurance coverage and the importance of documentation can be challenging. Patients may not fully understand why certain services are billed or the implications of their insurance policies.
Misunderstandings can lead to dissatisfaction when patients are unexpectedly billed for services, complicating the patient-provider relationship.
6. Frequency of Services
Insurance companies often scrutinize the frequency of services billed under CPT code 98940. Practices may face challenges in justifying the necessity of ongoing treatment, particularly if a patient requires frequent visits. This scrutiny can lead to claims being flagged for review, resulting in delayed payments or denials.
7. Keeping Up with Changes
The landscape of healthcare coding and billing is constantly evolving. Changes in coding guidelines, payer requirements, and insurance policies necessitate ongoing education and training for staff to maintain compliance.
Keeping up with these changes can be resource-intensive and may require regular staff meetings and training sessions to ensure everyone is informed.
Use of AT and GA Modifiers with 98940 CPT Code
CPT modifiers provide essential information about the services rendered, including whether multiple procedures were performed, the necessity of the procedure, the specific location on the body where it was conducted, and other critical details that can impact a claim’s status with the insurance payer.
AT Modifier with 98940 98940 Procedure Code
- When providing active or corrective treatment for acute or chronic subluxation, the AT (Acute Treatment) modifier must be included on claims for 98940 chiropractic code as well as 98941, or 98942 CPT codes.
- Claims for medically necessary services must contain the AT modifier; otherwise, they will be denied. However, the presence of the AT modifier does not always guarantee that the service is deemed reasonable and necessary, as contractors may deny claims after medical review.
- For maintenance therapy, no modifier is required when billing codes 98940, 98941, or 98942. In these cases, the AT modifier should not be included, as claims without it will be considered maintenance therapy and subsequently denied.
Chiropractic claims submitted with the 98940 modifier – AT – indicate that the provider is delivering active or corrective treatment for acute or chronic subluxation. This modifier should not be used for services classified as maintenance therapy.
Documentation Needed for Using 98940 CPT code
To ensure proper billing and reimbursement for CPT code 98940, accurate documentation is essential. Here are the key components that should be included:
1. Patient Information
- Full name, date of birth, and insurance details.
- Relevant medical history, including previous treatments and conditions.
2. Treatment Justification
- Clear documentation of the diagnosis (e.g., acute or chronic subluxation).
- Details of the clinical assessment supporting the need for treatment.
3. Treatment Plan
- Specific treatment goals and objectives.
- Outline of the frequency and duration of chiropractic care.
4. Session Details
- Date of service and location of treatment.
- Description of the specific procedures performed, including adjustments made.
5. Progress Notes
- Documentation of patient progress and response to treatment.
- Any modifications to the treatment plan based on patient response.
6. Use of Modifiers
- Indication of any modifiers applied (e.g., AT modifier) and the rationale for their use.
7. Consent Forms
- Signed consent from the patient for the treatment provided.
Optimizing 98940 CPT Code Reimbursement
To ensure maximum reimbursement for services billed under CPT code 98940, consider the following detailed strategies:
1. Accurate Documentation
- Detailed Records: Maintain comprehensive documentation for each patient visit, including the patient’s medical history, current condition, and specific treatment provided. This should include the rationale for each service rendered and the expected outcomes.
- Medical Necessity: Clearly articulate why the treatment is necessary. This involves linking the chiropractic interventions directly to the patient’s diagnosis and presenting evidence of how the treatment addresses the specific needs of the patient.
2. Use Appropriate Modifiers
- AT Modifier Usage: When providing active or corrective treatment for acute or chronic subluxation, ensure the AT modifier is included in claims. This modifier indicates the nature of the treatment and is essential for reimbursement.
- Avoid for Maintenance Therapy: Be cautious not to apply the AT modifier when billing for maintenance therapy. Claims without the AT modifier will be considered maintenance services and may be denied, affecting your practice’s revenue.
3. Stay Informed on Payer Policies
- Regular Policy Reviews: Regularly review each insurance company’s policies regarding chiropractic services. This ensures that your billing practices align with their requirements and that you are aware of any specific documentation or coding preferences they may have.
- Adapt to Changes: Stay updated on changes in coverage, payer guidelines, and any new regulations affecting chiropractic billing to prevent unexpected denials.
4. Educate Patients
- Communication: Clearly communicate with patients about their insurance coverage and the potential for out-of-pocket costs associated with their treatments. This transparency helps set realistic expectations and fosters trust.
- Importance of Documentation: Educate patients on the significance of accurate documentation and treatment plans. This can include discussing how their cooperation in providing necessary information impacts their insurance claims.
5. Utilize Correct Coding Practices
- Accurate Code Selection: Ensure all services are billed using the correct CPT codes. Review each claim carefully to confirm that appropriate modifiers and ICD-10 codes for diagnoses are included to prevent errors.
- Double-Check Claims: Implement a systematic review process for coding accuracy before submitting claims. This reduces the likelihood of mistakes that could lead to denials or delays in payment.
6. Implement a Robust Chiropractic Billing Software
- Practice Management Software: Use comprehensive chiropractic practice management software that includes claim tracking, billing automation, and reporting features. This technology can significantly reduce administrative errors and streamline the billing process.
- Regular Billing Reviews: Periodically review billing practices and workflows to identify inefficiencies and make necessary adjustments, enhancing the overall effectiveness of your revenue cycle management.
7. Monitor Claim Denials
- Track Denials: Keep detailed records of claim denials, including reasons for denial and patterns that emerge over time. Analyzing this data can help identify areas needing improvement.
- Address Recurring Issues: Develop strategies to address recurring denial issues. This might include additional training for staff or changes in documentation practices to reduce future denials.
8. Conduct Regular Training
- Ongoing Education: Provide continuous education for staff on the latest coding updates, payer requirements, and best practices for documentation. This ensures that everyone is well-informed and compliant with current regulations.
- Training Sessions: Hold regular training sessions or workshops to review key topics and discuss any updates in coding or billing practices, fostering a culture of continuous improvement within the practice.
9. Utilize Pre-Authorization When Necessary
- Pre-Authorization Requests: For certain treatments or high-cost procedures, consider obtaining pre-authorization from the insurance company to confirm coverage and minimize the risk of denials after services are rendered.
- Complete Documentation: Ensure that all required documentation is submitted with pre-authorization requests. This may include patient history, treatment plans, and any relevant medical records to support the request.
10. Hire Billing Experts
- Specialized Knowledge and Reduced Claim Denials: Hire chiropractic billing services. Billing experts possess in-depth knowledge of coding and insurance policies, ensuring accurate submissions and minimizing claim denials to improve cash flow.
- Time Efficiency and Enhanced Revenue Cycle Management: Outsourcing billing tasks allows healthcare providers to focus on patient care while experts implement strategies that optimize the entire revenue cycle, improving overall financial health.
Conclusion
In the complex world of chiropractic billing, utilizing the right strategies and expert support is essential for optimizing 98940 code reimbursement and ensuring a billing process. By staying informed, maintaining accurate documentation, and hiring billing experts, your practice can overcome common challenges and enhance its financial performance.
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