There are nearly 11,000 CPT codes to account for all the different variations of healthcare treatments. While your chiropractic practice will only need a fraction of these codes, it’s vital that the medical billing codes for chiropractors are current and accurately reflect the services rendered.
It’s intriguing how insurance providers differ in their assessment of chiropractic coding. There is a notable discrepancy in their criteria for determining medical necessity, with some adopting more rigorous standards, while others classify similar services as experimental, investigational, or lacking evidence.
Chiropractor billing encompasses submitting claims to insurance companies or third-party payers for services rendered by chiropractors. Accurate documentation and utilization of correct billing codes for chiropractic are crucial for maximizing reimbursement.
Here are some common chiropractic billing and coding requirements
1. UHC Claims Will Require GP Modifier For Therapy Codes
According to the most recent United Healthcare Network Bulletin, to align with Medicare billing protocols, ALL United Healthcare (UHC) claims, including those sent to UHC subsidiaries like Optum and UMR, will require the GP chiropractic billing modifier on therapy codes for payment to be considered for these services.
The following chiropractic billing codes require a GP physical therapy modifier, as appropriate.
92507 92508 92526 92608 92609 96125 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97530 97533 97535 97537 97542 97750 97755 97760 97761 97762 97799 G0281 G0283 G0329
Please note that some of these CPT codes are not applicable to the practice of chiropractic; however, the 97*** series of chiro CPT codes (including electrical muscle stimulation, therapeutic exercise, etc) are commonly utilized in chiropractic clinics.
So if you render and bill for 1-2 regions of CMT (98940) and therapeutic exercise (97110), then the 97110 chiropractic CPT code will receive the GP modifier.
2. Don’t Bill 97014/G0283(Electrical Stimulation) More Than Once Per Patient Encounter
97014 — This code is designed to cover unattended electrical stimulation that is not a part of wound care treatment. (Note: 97014 is not recognized by Medicare.) In accordance with CMS guidelines, chiropractors must use the code G0283 for Medicare patients.
Regardless of areas treated, don’t bill 97014 more than once per patient encounter. Also, if you bill the CPT code 97014 when the payer requires the alternative HCPCS code G0283, your claim will be denied. It’s crucial to note that United Health Care requires the same G0283 instead of 97014.
Make sure when using your chiropractic billing software for submitting claims, you use HCPCS code G0283 for submission of electrical muscle stimulation treatment to Medicare and the CPT code 97014 to other insurance payers unless the payer’s direction states otherwise.
3. The 97010 CPT Code is Described in the CPT Manual as Supervised Modality
CPT Code 97010 is defined as “Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy. The application of a modality that does not require direct (one-on-one) patient contact by the provider. Application of a modality to one or more areas; hot or cold packs.
Chiropractic CPT code 97010 is often misused and over-billed. The most common reason is that it’s difficult to establish and prove medical necessity for this service. The documentation doesn’t include an appropriate rationale for using this code. Here’s what the American Chiropractic Association (ACA) has to say about code 97010:
“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 common chiropractic CPT codes 98940-43 in instances when moist heat or cryotherapy is medically necessary in order 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.”
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. It means hot/cold pack services described by the CPT code for chiropractic – 97010 – are not separately billable when rendered to a Medicare patient. So 97010 will be a part of the primary service rendered to the patient, and in chiropractic, that will be a CMT code (98940-98942).
While some insurance payers operating as secondary to Medicare will cover 97010 when delivered in a chiropractic setting as a separate item. Do remember to include supportive documentation for hot or cold pack therapy CPT Code 97010:
- The area(s) treated
- The type of hot or cold application
4. Procedure Codes 97012, Mechanical Traction/Spinaltor
According to the CPT manual, mechanical traction is described as the force used to create a degree of tension of soft tissues and/or to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body’s own weight to create the force).
A common question is whether roller table-type traction meets the above requirement. Roller table-type traction normally meets the requirement of autotraction, the use of the body’s own weight to create the force. It is the position of the American Chiropractic Association that modalities such as mechanical traction are not included in the work of the CMT codes. Code 97012 should be used to describe these services, subject to documented medical necessity. When you do chiropractor billing, make sure to document the type (e.g., static, intermittent, autotraction), amount of force (pounds), duration (time), and angle of pull (degrees).
5. 97110 Therapeutic Exercise vs 97530 Therapeutic Activity
CPT code 97110 (Therapeutic Exercise) incorporates one parameter (strength, endurance, and 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 exercise (for flexibility), and gymnastic ball (for stretching and strengthening).
Diagnoses could be:
Loss or restriction of joint motion, strength, flexibility, functional capacity, or mobility from a specific disease or injury.
Consider chiropractic ICD-10 codes from the following groups:
M47 M48 M50 M51 M53 M54 M62 M99 S13 S16 S23 S29 S33 S36 S39
CPT code 97530 is therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes. This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner.
Therefore, dynamic activities that work towards functional performance such as lifting, bending, pushing, pulling, jumping, and reaching would be billed as 97530.
Coders should determine how many outcomes are expected by the particular procedures being performed.
- If only one outcome is intended by the exercise, CPT code 97110 should be used.
- Where more than one outcome is expected where increased motion, flexibility, strength, and/or improved proprioception is intended, CPT code 97530 should be used.
The takeaway is that if the documentation shows that the patient has a loss of strength, range of motion, endurance, or flexibility, then 97110 can be justified. However, the treatment goals for exercise should clearly document anticipated improvement in those same parameters.
Remember, therapeutic exercises and therapeutic activities should be clearly described in your initial treatment plan and document the intended clinical outcome as well as how the procedure is performed.
6. Direct Patient-Chiropractor Care CPT Codes
For chiro billing, you can only quantify the time that is spent with direct patient-chiropractor care; the client waiting for equipment or resting in your office doesn’t qualify as direct care, so it can’t be billed.
Refer to these ranges of billing codes for chiropractic to find the one that is most appropriate for chiropractic services rendered:
- 97032-97039
- 97530-97546
- 97110-97150
Tips for Accurate Chiropractic Billing and Coding
Chiropractic billing can be challenging due to the complex chiro CPT codes and documentation requirements. By implementing these chiropractic billing tips, practices can improve their billing processes, increase revenue, and provide better service to their patients.
- Understand CPT codes: Select appropriate medical billing codes for chiropractors for treatments and use separate codes for each service.
- Use modifiers correctly: Apply modifiers to provide additional information about services or procedures.
- Communicate clearly: Explain the chiropractor billing process to patients, including coverage and potential costs.
- Keep detailed documentation: Record patient information accurately and document treatment details thoroughly.
- Submit claims promptly: Be aware of submission deadlines and include all necessary information in each claim.
- Verify insurance coverage: Regularly confirm patients’ insurance status and coverage for chiropractic services.
- Stay updated on coding changes: Keep abreast of coding guidelines and updates to ensure accurate billing.
- Utilize technology: Use chiro billing systems with invoicing, billing and payment functionalities to automate and simplify the billing process.
- Implement training and education: Attend seminars or workshops to stay informed about billing practices and regulations.
If in-house billing is too demanding for you and your staff, zHealth will reviews your chiropractic billing codes before claim submission so you can get the maximum possible reimbursement. We offer a comprehensive range of chiropractic medical billing services including coding review, AR follow-up, denial management, payment posting, credentialing, and more. Our chiropractic billing software makes it easier for you to keep track of all submitted claims and ERAs/EOBs. For in-detail information about how we can help you achieve maximum reimbursement, contact us right away.
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The ‘Tricky’ 97140 Chiropractic CPT Code: How to Use This Code Appropriately
Know the Top Chiropractic CPT Codes That Can Save Your Billing Time
