Editor's note: This is a response to the two-part series by Dr. K.S.J. Murkowski ("CPT Confusion," DC, March 24 and April 7, 1997) from Kurt Hegetschweiler, DC, ACA president, and Lowry Morton, DC, ACA board chairman. Following their comments, the ACA has provided additional information "relating to the proper us of CMT codes."
The American Chiropractic Association was intimately involved in the development of the new chiropractic manipulative therapy (CMT) codes, and their implementation into Medicare's RBRVS system. While we share the author's interest in clarifying any confusion, we believe the article contains some serious misinterpretations of federal Medicare regulations and general coding procedures. We hope to point out some of these inconsistencies, and outline ACA's position to clarify any confusion that may relate to these new and important codes for the profession.
The article goes to great lengths to demonstrate the way an evaluation and management code may be utilized with a CPT code, other than a CMT code, to maximize reimbursement for non-Medicare payers. The use of the osteopathic manipulative therapy (OMT) code is featured in a series of examples in this regard. The ACA must stress that the rules that apply to the use of an E&M code in connection with any manipulation code are the same, and not, as the article seems to imply, different when the doctor is utilizing a CMT code. Whether a CMT or OMT or other manipulation code is utilized, the rules and procedures related to the use of an office visit or E&M codes are exactly the same. Therefore, there is no advantage in rejecting the use of the CMT code when utilizing a related office visit or E&M code. Further, we question the appropriateness of attempting to code a service to maximize reimbursement rather than to accurately describe the service performed.
It is important to stress the need for caution in utilizing an OMT code. The ACA recommends that the doctor ascertain in advance whether the utilization of an OMT code is authorized under state law and viewed as appropriate by the third-party payor.
Of particular concern is the issue raised in the article concerning the application of federal Medicare rules and the use of CMT. The article states that federal Medicare rules (specifically 2250 and 2251.1 of the Medicare Carrier's Manual) provide that "all noncovered services are not to be billed to Medicare," and poses the question: "How then is the pre/post-work (call) included in the normal CMT without a federal law change?" Dr. Murkowski goes on to suggest that the use of CMT is somehow posing a problem for chiropractors and concludes: "This, in my opinion, is in direct conflict with what has been previously stated by the federal regulations, their administrators and information from the ICA and ACA."
The first point is that no where in the cited Medicare regulations does it state that "noncovered services are not to be billed to Medicare" as the author purports. Indeed, there are circumstances recognized by federal regulation in which a chiropractor must submit what he knows to be a noncovered service to obtain a Medicare denial for Medicare secondary and other purposes. This is clearly spelled out in the Medicare Carrier's Manual at 3043, which provides the following:
3043. OBLIGATION OF PHYSICIAN OR SUPPLIER TO BILL FOR SERVICES WHICH ARE NOT COVERED
Ordinarily, a physician or supplier does not bill the Medicare program for noncovered services. However, if the beneficiary (or his/her representative) believes that a service may be covered or desires a formal Medicare determination, the physician or supplier must file a claim for that service to effectuate the beneficiary's right to a determination. Instruct physicians or suppliers to note on the claim their belief that the service is noncovered and that it is being submitted at the beneficiary's insistence.
Secondly, 2250 and 2251.1 of the Medicare Carrier's Manual states in part:
Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of hands. No other diagnostic or therapeutic service furnished by a chiropractor, or on his order, is covered.
Chiropractic manipulative treatment (CMT) is by definition "treatment by means of manual manipulation" covered under the Medicare regulation and also specifically covered under the Medicare statute. A2000 previously described this covered "treatment" for many years. Today, the new CMT codes will describe this service.
We are concerned that in addition to misinterpreting Medicare regulations, the article also conveys a false impression in terms of the ACA's position on what is appropriate for Medicare billing purposes. For example, the article states that the ACA is suggesting that "DCs should be moving toward the practice of area (region) and pain treatment only, and moving away from a vertebral subluxation complex-based/full spine practice." The article also states that the ACA is encouraging the use of lower level CMT codes because of potential governmental scrutiny. Both contentions are incorrect. According to a 1992 survey conducted by the ACA and the work of the Lewin Group, the ACA anticipates that, on average, CMT code 98940 (1 and 2 regions) will be used 24% of the time when describing chiropractic spinal manipulative treatment services; CMT code 98941 (3 and 4 regions) will be used 63% of the time when describing chiropractic spinal manipulative treatment services; and CMT code 98942 (5 region) will be used 13% of the time when describing chiropractic spinal manipulative treatment services. These projections are based on the actual practice of field doctors and does not constitute an ACA effort to limit or alter doctor practice patterns. Patient services must always be based upon the independent professional clinical judgment of the doctor. The codes utilized merely reflect and describe the service performed pursuant to this clinical judgment. The ACA is not encouraging or suggesting anything other than that the doctor utilize the procedural code that best describes the service. We can assure doctors that the CMT codes have been thoroughly reviewed and approved by HCFA for use by chiropractors in the Medicare program, and the ACA's position on these codes is consistent with this review process. The history in this regard has been well documented in ACA publications and we will not attempt to detail this extensive record.
The ACA must again stress that code utilization whether for Medicare or non-Medicare purposes must be based on the need to use the code that best describes the service and should not be geared upon efforts to increase reimbursement. We would point out that the recently enacted Health Insurance Portability and Accountability Act of 1996 establishes a new federal health fraud provision which adds to the armament of the federal government by providing criminal sanctions of up to five years imprisonment for "knowingly and willfully" making any materially false, fictitious, or fraudulent statement or representation in connection with the delivery of or payment for health care benefits, items or services in relation to any public or private health care benefit program, not just Medicare alone. (244, False Statements Relating to Health Care Matters, Health Insurance Portability and Accountability Act of 1996.)
In summary, we feel the article "misses the mark" in a number of serious and substantial areas as it relates to appropriate coding advice. Its attempt to "clarify" confusion has, we fear, only suggested approaches that may have potential problems. We do agree with the author's recommendation that doctors check with state board of examiners and state associations for assistance with coding and scope of practice issues. We would also suggest that chiropractors contact the ACA for the most updated, accurate and complete information on CMT usage. Attached for your readers are additional common questions and answers relating to the proper use of CMT codes.
Choosing the Correct CMT Code
Chiropractic providers are encouraged to select the CMT code which most closely describes the manipulative service that they have administered on any given patient visit. As noted previously, the code descriptors are based upon the number of body regions receiving manipulation.
Regardless of how many manipulations are performed in any given spinal region (cervical, thoracic, etc.) it counts as one region under the CMT codes. For example, chiropractic manipulation applied to the occiput, C3 and C5 during one patient visit would represent treatment of one region (cervical) and, if this was the only manipulation performed during this visit, the appropriate code to use would be 98940.
It is appropriate to use code 98943 to describe chiropractic manipulative treatment to one or more extraspinal regions, regardless of how many individual manipulations are actually performed. The CMT code 98943 can be used either by itself or in conjunction with a spinal CMT code. In those cases when 98943 is used in conjunction with a spinal CMT code, it is necessary to add a -51 modifier (98943-51). The addition of the -51 modifier denotes a 50% reduction in the total relative value unit of 98943 under the Medicare fee schedule. Other third party payers may interpret the -51 modifier differently.
When to Use E/M Codes
The CMT codes differ from 97260-61 in that they include a cognitive component (i.e., a pre and post manipulation assessment that includes: documentation; chart; imaging review; test interpretation; care planning; patient assessment (e.g., palpation); patient preparation (e.g., positioning and setting up equipment); post-adjustment assessment; readjustment if necessary; post-adjustment instruction to the patient; chart documentation; arrangements for other services; consultation and communications; reporting and review of any appropriate literature), in addition to performance of the manipulative procedure. However, E/M codes can be used on the same day of service as a CMT code when clinically warranted. The use of an E/M code in conjunction with the CMT codes requires a -25 modifier attached to the E/M code (e.g., 99212-25). The -25 modifier indicates that a significant, separately identifiable evaluation and management service was provided by the same chiropractic physician on the same day as the provision of CMT.
It is appropriate to use an E/M code (with an attached -25 modifier) in conjunction with a CMT code when the level of evaluation exceeds the usual preservice or postservice work, meets the level of service required by the E/M code used, and is supported by appropriate documentation.
Documentation
Clinical justification for administering CMT and specific documentation protocols should be based on the DC's clinical judgment. However, documentation of clinical justification for administering CMT to any given area should be recorded in the patient chart on the day of the patient visit and include the following: 1) a subjective record of the patient complaint; 2) physical findings to support manipulation in a region or segment; 3) assessment of change in patient condition, as appropriate; 4) record of specific segments manipulated.
Most Frequently Asked Questions Why does the 1997 Medicare fee schedule show a lower reimbursement for the new CMT code 98940 than that which was received for A2000 in 1996 in some geographic regions?
The total RVU for 98940 is identical to the total RVU that had been assigned to A2000 in 1996. Decreases in reimbursement rates between the 1996 fee for A2000 and the new CMT code 98940 is caused primarily by a decrease in the Medicare conversion factor for all nonsurgical services and the addition of a work value conversion factor. The nonsurgical conversion factor decreased from $34.6293 in 1996 to $33.8454 in 1997. These conversion factors, which are multiplied by the total RVU in order to establish the correct payment under Medicare, would have caused lower reimbursement for A2000 in 1997 as well.
Will I ever use the second and third level CMT codes (98941 and 98942)?
According to a 1992 survey conducted by the ACA and the work of the Lewin Group, the ACA anticipates that, on average, CMT code 98940 will be used 24% of the time when describing chiropractic spinal manipulative treatment services, CMT code 98941 will be used 63% of the time when describing chiropractic spinal manipulative treatment services and CMT code 98942 will be used 13% of the time when describing chiropractic spinal manipulative treatment services.
Will HCFA require an x-ray to "demonstrate a subluxation" for each region receiving manipulation under the new codes?
Under current Medicare coverage directives, a chiropractor must have a documenting x-ray demonstrating the existence of a spinal subluxation. It is the opinion of the American Chiropractic Association that an x-ray should not be required for each region receiving CMT under the new codes. The ACA views such a requirement for each region receiving manipulation to be unnecessary and we are concerned that it will lead to excessive radiation exposure to the patient. Instead, we have proposed to HCFA that the x-ray requirement be limited to the primary diagnosis (i.e., subluxation), provided there is clinical justification for manipulation of subsequent spinal regions documented in the patient chart.
A small number of carriers initially expressed the intent to require an x-ray for each region receiving manipulation. The central office at HCFA has been contacted by the ACA regarding this situation and recently issued a policy that is consistent with the ACA's position on this matter. If your carrier has a policy in conflict with this position, please contact the ACA immediately.
Can I bill for other services, such as therapies, on the same day as the CMT codes?
Yes, you can bill separately for any service that is not considered to be part of the pre and post manipulative service provided under the CMT codes. This includes physical medicine codes. It is not necessary to use a modifier when billing a physical medicine code with a CMT code. When billing these services under Medicare, keep in mind that HCFA does not cover any service other than manipulation of the spine. For Medicare patients, these services should not be billed without an appropriate disclaimer that the services are being billed for MSP or other purposes and not for Medicare reimbursement.
How do the new CMT codes affect the current Medicare coverage policy for chiropractic services?
Other than the fact that the three spinal CMT codes replace A2000 in the Medicare fee schedule, there are no other changes to Medicare reimbursement policy for chiropractic services at this time. The new CMT codes do not in any way change the Medicare Statute, which specifies that Medicare will cover only chiropractic manipulation of the spine for the purpose of correcting a subluxation. The ACA is working towards other changes in Medicare payment policy but these issues have not yet been resolved.
Are DCs now required to use the new CMT codes for all payers?
A. You will need to use the CMT codes for Medicare patients in 1997.
The three spinal CMT codes replace A2000 under the Medicare fee schedule, effective January 1, 1997. However, some carrier medical directors are offering a 30-90 day grace period for the use of the new codes. During the grace period you can use either A2000 or the new CMT codes. Check with your local CMD or state chiropractic association to see if a grace period is in effect in your area.
B. Insurers other than Medicare may also be adopting the new CMT codes.
The CMT codes are listed in the AMA's CPT '97 and it is probable that many third-party payers will begin to accept and/or require the use of the CMT codes. The rate at which this occurs will vary according to policy and the time it takes to incorporate the new codes into their computer systems. The ACA believes that doctors of chiropractic should use the CPT code(s), including the CMT codes, that best describes the service(s) that they provide, as long as the use of those codes is in accordance with state law. To avoid billing problems, you may want to check with your local carrier before beginning to use the CMT codes. If you would like information about the CMT codes to send to your local carrier, please contact the ACA.
In the paragraph before the code descriptors in the CPT '97 book it states that additional evaluation and management services may be reported separately using the modifier -25. What exactly does this mean?
Although the CMT codes do include a cognitive component within the pre and post-manipulative phases of the treatment encounter, there are times when it is appropriate to bill a separate E/M code on the same date of service as a CMT code (e.g., new patient visit, established patient with a new condition, etc.). When this occurs, it is necessary to attach a -25 modifier to the E/M code that is billed (e.g., 99212-25). The -25 modifier signals the payer that an additional service was performed, above and beyond the usual pre and post-service work associated with the CMT code. You must use the -25 modifier any time you bill an E/M code on the same date of service as a CMT code, regardless of what E/M code you use.
How do I fill out the HCFA claims forms when using the new codes?
Under the new chiropractic manipulative treatment (CMT) codes, doctors of chiropractic may now bill for a service which can include manipulations in up to five spinal regions. For Medicare purposes, a primary diagnosis of subluxation is required for each spinal region manipulated, backed by a secondary diagnosis (from categories I, II, or III) as appropriate. This could potentially lead to 10 separate diagnoses: five primary and five secondary. However, both the HCFA-1500 claim form (Item 21) and electronic billing form in the National Standard Format (NSF) Record FAO (fields 30-33) currently have space for up to four diagnoses only. Given this situation, an addendum to the Carrier Medical Director's Chiropractic Model Policy outlines the appropriate way to fill out the claims form as follows:
- For CMT code 98940 (1-2 regions), list all appropriate diagnoses (up to two primary and two secondary) in either item 21 of the HCFA-1500 or field(s) 30-33 of the NSF Record FAO.
- For CMT codes 98941 (3-4 regions) and 98942 (5 regions), list the two most clinically significant primary diagnoses and the their two accompanying diagnoses in either item 21 or field(s) 30-33. Then select the one of those two primary diagnoses that you consider to be most significant and enter it as item 24E on the HCFA-1500 or field 14 in NSF Record FAO.
Although the claims forms will only contain the diagnoses for two regions treated, if CMT for more than two regions is being billed, the clinical record MUST document the reasons for treating the other regions.
Are physical therapy modalities (e.g., 97010 hot/cold packs) bundled into the CMT codes?
The physician work included in chiropractic manipulative treatment (CMT) codes was laid out in a work value survey of the chiropractic profession conducted in the spring of 1996. Physical therapy modalities (including 97010) were not part of the work described in that survey. It is the position of the American Chiropractic Association that physical therapy modalities are not included in the work of the CMT codes. The appropriate physical modality codes should be used to describe these services, subject to documented medical necessity.
