Editor's note: DCs Jerilynn Kaibel and Craig Little respond to some commonly asked questions about the new Physicians' Current Procedural Terminology (CPT '97). Drs. Kaibel and Little, members of the American Chiropractic Association, were the first chiropractors ever appointed to the AMA advisory committees that developed the codes.
How will this coding change impact individual state equality laws?
It is the view of the ACA's legal department that CMT codes will not interfere with current state equality statues since:
- The CMT codes will not replace 97260 and 97261, but will broaden the available choice of codes.
- If an insurance policy writes out a service unique to chiropractors, such as manual manipulation of the spine, and state law permits such exclusion, it makes no difference whatsoever how such manipulation is described (i.e., whether with 97260, A2000, a CMT code or an osteopathic manipulative treatment code), if the service is manual manipulation, it will not be covered in any event.
- The basic scheme behind insurance company evasion of state insurance equality law requirements was and is to discriminate against the services unique to chiropractors and not against chiropractors or chiropractic itself. The specific nature of the CMT codes actually makes it easier to demonstrate (in those states in which it is relevant) discrimination by an insurance company directly against chiropractors and not against the services they provide.
Why was the coding change necessary? There were several reasons why the coding change was necessary. Currently under the Medicare reimbursement system, the total range of chiropractic services are represented by a single code: A2000. The A2000 code is listed under the HCFA Common Procedure Coding System (HCPCSA) rather than as a CPT code. There are multiple problems with using the A2000 code. First, it is impossible for a single code to adequately represent the whole range of covered services provided by chiropractic physicians. More importantly, the work values of CPT codes are developed through an established measurement process which is based on the time, technical skill and mental effort required to perform each service.
Because A2000 is not a CPT code, HCFA assigned a work value without documenting precisely how that work value was achieved. While the ACA has previously been quite successful in increasing the value of A2000, the fact that HCFA has not documented the process used to arrive at this work value makes it extremely difficult to continue to argue effectively that the current work value of A2000 is inadequate.
Encouraging HCFA to allow chiropractors to use CPT 97260 to describe manipulative services was deemed impractical for several reasons. CPT 97260 is defined as a separate procedure code, and such defined procedures are commonly carried out as an integral part of a total service, rather than a total service by itself. CPT 92760 does not include a cognitive physician work component to cover aspects of care such as care planning, coordination of care or chart documentation. Because of this, CPT 97260 is valued at a very low rate which consequently leads to a very low reimbursement rate. The low reimbursement rate for 97260 is rapidly becoming a more critical problem as many payers continue to shift toward the RBRVS payment system.
The ACA proposed codes include a cognitive component which encompasses the clinical judgment and the technical skill required when managing a patient complaint with manipulative therapy. Inclusion of a cognitive component should increase the relative work value of the ACA proposed codes, resulting in an increase in reimbursement to chiropractors for manipulative therapies beyond that which could be achieved with CPT 97260.
How were the new CPT codes developed?
The Medicare resource-based relative value scale for physician services was implemented on January 1, 1992. By law, HCFA is required to review all work relative value units (RVUs) for physician services in the Medicare Fee Schedule every five years. HCFA initiated such a review in 1994. To develop appropriate chiropractic comment on the A2000 HCPCS, two steps were necessary:
- The first step was to obtain chiropractic representation on the two American Medical Association (AMA) committees responsible for making coding change recommendations to HCFA: the CPT and RUC Committees. The CPT Editorial Panel and RUC Committees were comprised of MDs and DOS only, with the exception of the chairperson of the CPT HCPAC and RUC HCPAC who have recently been seated with the panels to represent non MD/ DOS with a voting seat.
Approximately three years ago, the AMA formed advisory committees (Health Care Professionals Advisory Committees or HCPAC) to both CPT and RUC. The members of these HCPAC committees are representatives from various national associations representing the non MD/DO health professions and included optometrists, podiatrist, psychologists, etc. Initially, there was no chiropractic representation on either of these committees. The AMA felt that chiropractic representation was not necessary since chiropractors were not allowed to utilize CPT codes under Medicare.
After two years of persistent efforts on the part of the American Chiropractic Association, the ACA was invited the AMA to appoint a chiropractic representative to both the CPT HCPAC and RUC HCPAC committees. This occurred in August 1995. Craig Little, DC (CPT HCPAC) and Jerilynn Kaibel, DC (RUC HCPAC) were appointed as the ACA representatives to these committees.
- The second step was to develop a credible proposal for a chiropractic coding change that could be presented to the CPT and RUC Committees.
Currently, HCFA recommends using the modified Delphi process for establishing work RVUs for services not reported in the initial RBRVS study which was done at Harvard University. To follow the HCFA recommended protocol, the ACA hired the prestigious health care consulting firm of Lewin-VHI to conduct the study necessary to assist in the preparation of final five year review comments to HCFA and develop accurate work values for chiropractic services.
The ACA, in consultation with Lewin-VHI, selected a total of 19 chiropractors (one who was a DC/DO) to represent a cross section of chiropractors in the U.S. on two panels: the Technical Advisory Panel and the Consensus Panel. The chiropractors (and one osteopath) on these panels were responsible for assessing the appropriateness of the existing A2000 HCPCS code for chiropractic spinal manipulation and for developing new codes, and preliminary work values, for chiropractic manipulation services. The ways in which these chiropractors were chosen and the methodology that was used in this assessment and development process was set by Lewin-VHI rather than the ACA and was based on HCFA recommendations.
The product of this consensus process, which subsequently became the basis of the ACA's Medicare coding change proposal, was a document title "Development of a New Coding Structure and Associated Work Values for Manipulation Services."
It was the ACA's original intent to propose generic physician level manipulation codes. However, proposing generic codes was not possible during this coding cycle because of the moratorium on coding changes that had been set by the AMA. The only coding changes which could be submitted were those representing new technology or scheduled for the five year review. A2000 was up for review in the current coding cycle, thus presenting us with the small window of opportunity, but because A2000 is currently narrowly defined as "chiropractor manipulation of spine," any changed proposed had to remain chiropractic specific.
E/M services are referenced in the CMT preamble. Does that mean that Medicare will now reimburse the chiropractic doctor for that service?
No reimbursement will be made directly from Medicare. That will be listed in the EOB as a noncovered service. This service can then be forwarded to a secondary payer if one exists or the patient can be billed for that service if they have been advised that this service will not be reimbursed by Medicare.
Extraspinal services are coded as 98943. Does this mean that Medicare will now reimburse the DC for that service?
No reimbursement will be made directly from Medicare. Reimbursement for chiropractic services remain manipulation of the spine. This, too, will be returned as a non covered service on the EOB and the secondary payer or patient can then be billed for this service if the appropriate disclosures have been made prior to the service being performed.
If a patient presents with a cervical complaint, and I routinely manipulate the patient's entire spine, will I be reimbursed for five regions?
This would not be appropriate to utilize the higher level code (98942 representing five regions) if the patient's complaints and physical findings did not substantiate that level of service in compliance with Medicare guidelines.
Will the new CMT codes be utilized by the private insurance companies?
It should be anticipated that the private payers will utilize the new CMT codes although this conversion might take longer than the conversion by Medicare on January 1, 1997.
What is meant by "interim"?
All new codes which are introduced into the CPT coding system remain "interim" for a period of one year. Since CMT codes are new to the CPT coding system, they will be considered "interim" for this period.
What is the advantage to chiropractic being involved in the CPT System?
We have the opportunity to monitor and comment on any new code and value request being proposed by any profession. The American Chiropractic Association will have the ability, through the positions on CPT HCPAC and RUC HCPAC to offer opinions with regard to the various proposals as they come forth.
If the CMT codes do not meet the needs of the chiropractic profession, will we have the opportunity to make changes?
There is a process by which, with the appropriate documentation and arguments, that changes in the codes can be affected.
Do the CMT codes belong to the American Chiropractic Association?
No, the CMT codes belong the American Medical Association as the CPT system is owned by the AMA, and the AMA has editorial control over the codes appearing in CPT. RBRVS is the relative value payment schedule instituted by Medicare which utilizes the CPT coding system. The ace proposal sought an increase in the relative value for chiropractic services under Medicare. How can this be budget neutral?
Total budget neutrality will be maintained in the RUC process through adjustments to the conversion factors applicable to ALL Medicare services. Various codes may have their values increased or decreased during the review process, and of course, many codes may remain unchanged. Increases in the payments to chiropractors under the proposal would be paid by an adjustment to the conversion factors applicable across the board to all Medicare providers.
What positive effect will the new codes have for the profession?
Establishing a procedure description for chiropractic doctors that will substitute for the numerous non uniform coding schemes will assist chiropractic doctors in maintaining the appropriate relative value for their services, with consideration to individual, private and federal payer systems. The proposal will have a positive effect on the chiropractic profession due to the seriously low established work values for CPT 97260 and the multiple problems that are inherent with the A2000 code.
