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Coding & Billing Q&A

John Kelly – ANJC Insurance Consultant

Recently I had to start billing extra-spinal manipulations (98943) to one insurer with a modifier -51, and now those claims are reduced by 50% on the payment for the 98943. Can they do this? How do I get this fixed?

Unfortunately, at the moment they can do this. This carrier published the policy in November of 2008 requiring the 98943 code be submitted with a modifer -51 appended in order to qualify for reimbursement. According to everything I have researched so far, this is not inappropriate per AMA CPT coding rules and guidelines. I say “so far” because I am continuing to look for some exception or guidance to counter this position.

Modifier -51 is for “Multiple Procedures.” This modifier makes reasonable sense from a general perspective. When a patient is in an office for a visit, many procedures can blend together and the preparation, decision making, time, and actual work effort can overlap. For example, a person with multiple broken fingers would not require two separate examination processes, patient positioning, separate casting services as in putting away and taking out equipment between fingers,etc. There would be a reasonable expectation of a somewhat reduced service on the second finger.

But the same reasoning does not apply for physical therapy services,for example, and they are specifically listed as an exception to the modifier -51 because the AMA obviously recognized that each therapy involved its own time, work and effort regardless of the combination of services. There is also an exception for supplies because two braces are twice as much as one brace, not one and a half times as much. This should also be the case for subluxations of completely separate anatomic sites. Yes, there is a related clinical diagnosis and nexus, but the palpations and examinations are no less time-consuming or effort-intensive than those of the spinal subluxations.

98943 should be considered a separate Primary Procedure, but for now it appears under these guidelines that it’s not. On paper it seems appropriate, but in my opinion it violates the spirit of the AMA’s real intent for the proper use of the modifier.

So, what do you do?

For now,follow the submission requirements and then appeal it stating the extra-spinal procedure should be considered as an additional Primary Procedure, not a reduced Multiple Procedure. It will have to go through two levels of internal appeal before getting an independent chiropractor who may give you a fairer decision. To a large extent, you are contractually bound to their policies.

A manufacturer of an inversion table suggests that I will be reimbursed under 97530 for therapeutic activities, but another said it should be an unlisted code. How should I be billing an inversion table for inversion therapy?

Good question, but be careful of thinking of devices in terms of the therapies they provide. Often a manufacturer or a technique instructor will extend coding advice based on what they feel the device or technique is worthy of accomplishing—or worse yet—what other doctors have been reimbursed for when they billed it.

An inversion table is simply a gravity-based mechanical traction device and should only be billed as 97012. There is no need for further explanation of what device you are using, but you should be aware of any policies that prohibit participating providers from billing certain therapies or devices. If you bill 97012 and get paid, but the carrier you are contracted with has had a published policy prohibiting submissions for reimbursement for the use of gravity traction or inversion tables, you may be subjected to an overpayment demand and maybe even worse.

You’ve done the right thing inquiring with a coding expert for this; many others could have avoided serious misery if they did the same. It’s a good practice to ask about any devices or services you are uncertain about.

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John. Kelly, in-house insurance consultant to ANJC, is a former Senior Investigator for Aetna insurance and currently assists providers in education, billing & coding compliance, mock audits, and post payment audit dispute or defense through his private business Kelly Coding & Compliance, LLC. For more information .