All chiropractic patients should be given specific exercise recommendations as part of their chiropractic treatment, and then more exercise guidance as part of their wellness program. Athletes being treated for sports injuries, whether caused by direct trauma or overuse, need to be taught how to correctly stretch and strengthen in order to return to their sports activities and improve their performance. Anyone who has been injured in an auto collision, or who has experienced an injury on the job, will need exercise guidance to regain function and prevent weakness and re-injury. And all patients who are interested in wellness can benefit from chiropractic recommendations regarding spinal fitness exercises, along with specific encouragement to stay active, while using correct body mechanics. This means that essentially all patients will need to receive chiropractic rehab services at some point in their chiropractic care.
Exercise Instruction
Most doctors of chiropractic frequently use some form of exercise instruction in their offices. The survey conducted by the National Board of Chiropractic Examiners in 2000 found that 98% of chiropractors reported using "corrective and/or therapeutic exercise" as part of their treatment of musculoskeletal conditions, and that more than 61% of their patients received exercise recommendations.1 Unfortunately, many of these doctors fail to ask for or receive any payment for this additional appropriate service.
With a few minor changes in office procedures, most chiropractic practices could be generating rehab income. Barring a few exceptions, chiropractic scopes of practice and insurance regulations permit licensed doctors of chiropractic to perform, bill for, and be paid for providing rehab services to their patients. A few states do limit chiropractic rehab to spinal exercises, so it is important to know your individual state's practice laws, workers' comp procedures, and insurance regulations.
Doing Rehab in a Small Office
Very little additional space or equipment is needed when an office adopts the popular "low-tech" rehab approach. Since the patients do their exercises at home, the rehab sessions can often be done in the adjusting room or an exam room. The most space- and cost-efficient method is to have a multi-exercise unit mounted on the wall in one or several rooms. This way, patients can learn to do the exercises using elastic tubing or a cervical resistance bar, and then leave with an at-home version of the office equipment.
The cost of the home exercise equipment is much less than the fee for doing supervised exercises on a machine. In addition, the patient can do the exercises when it's convenient, and even take it along on travels. Billing for the home exercise equipment is usually by CPT 99070, although some insurance companies will request a more specific HCPCS code.
The codes that are used for the type of rehab services we provide are all based on the 15-minute, direct-contact definition. CPT 97110 - Therapeutic Exercise is the broadest and least controversial of the rehab codes. It is the easiest code to use, and the one that most practices should start out with. The reimbursement for 97110 varies considerably with plans and among states, but it is usually between $25 and $35.
The definition of CPT 97112 - Neuromuscular Re-education includes "improving proprioception, coordination, balance, and posture,"2 so it is reasonable to use this code to bill for spinal stabilization, posture-changing, and wobble board exercises. Since these are more specialized exercises, this code is often reimbursed a bit higher - $30 to $45. However, because it has often been misused to bill for myofascial release and trigger-point stimulation, insurance companies often question this code.
And finally, CPT 97530 - Therapeutic Activities, which is defined as "dynamic activities to improve functional performance," is the most complex procedure of the three, and is usually paid at a higher rate ($40 to $60). Since this service calls for expert skills and knowledge, insurance companies and workers' comp boards often look for more in-depth documentation, and it's important to state what function and/or performance is being improved during this session.
The Need to Document
No matter which code is used, the most important factor to consider when documenting rehab is to separate the rehab notes from the adjustment notes. Since this is going to be billed as a separately identified professional service, the documentation must not be hidden in the adjustment notes; it must stand out as an additional procedure. This can be done in any number of ways, depending on the specific documentation methods used. Then it's a matter of recording what the patient did, since rehab procedures are active, not passive treatments, and the patient must do the exercises while the doctor teaches, supervises, and corrects the biomechanics.
Since there are no billing codes for unsupervised exercising, the documentation must demonstrate evidence of supervision. Also, since the codes for rehab services are based on 15-minute intervals, it must be obvious that such intervals of direct supervision occurred.
Two-Way Benefits With Rehab
Including exercises as an integral part of chiropractic care is easy and very beneficial. Not only do patients appreciate the doctor who gives them specific, corrective exercises; they are also willing to pay for this additional service. In fact, most chiropractors who have added rehab to their practices have seen an influx of new patients referred in specifically because this additional service is now available! Chiropractic rehab is appropriate for current patients as required, and also stimulates new patients.
References
Kim Christensen, DC, DACRB, CCSP, CSCS
Director, Chiropractic Rehabilitation and Wellness Program
PeaceHealth Hospital
Longview, Washington
kchristensen@peacehealth.org
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