Q: I adjust the full spine on all of my patients and bill CMT code 98942. I have noticed recently that code 98942 is increasingly rejected with the statement on the EOB typically noting "level of service was not substantiated." Why is this happening, and what can I do to substantiate 98942 on the billing form?
A: To substantiate the use of the code 98942, you must have all five regions of the spine in your diagnosis. The five regions as defined by CPT are cervical, thoracic, lumbar, sacrum and pelvis. Therefore, you need separately distinct diagnoses for each region. These diagnoses, of course, will be in the chart notes and on the billing form.
I realize that billing form CMS-1500 only has four areas for diagnosis in block 21, and that code 98942 requires five. How can it be done? For paper claims, you may place additional diagnoses in block 19, where it states "reserved for local use." Further, electronically billed claims also may allow this practice, but in either case, check with your individual clearing house and/or insurer for their specific protocol and use of block 19. Of course, an attachment to the claim may be sent to add the specific diagnoses necessary.
Therefore, the choice of code is one diagnosis. If you only have three to four regions of the spine diagnosed, the appropriate code would be 98941; if only one to two regions are diagnosed, then 98940 would be used.
In any of the above cases, note that it does not state the regions adjusted, but the areas diagnosed. In your original question, you state that you use 98942 on all of your patients. This, of course, is correct for your style or technique, but for the use of 98942, every patient must have diagnoses for all five regions. This course is possible, but not probable, as some patients will certainly have only one, two, three or four spine regions in the diagnosis. In those cases, the appropriate CMT of 98940 or 98941 should be utilized. When choosing the proper CMT code, be mindful that all insurers will correlate the regions of the spine to the CMT code, and they must match.
Bear in mind, it is not uncommon for many (if not most) chiropractic doctors to perform a full-spine or multilevel manipulation, even when the diagnosis is a single region. This is a matter of technique and individual style. While the merits of differing techniques and styles may be debated, the factor in choosing the CMT is not one of style, but of diagnosis. My father, who was a practicing DC for 37 years, routinely adjusted several segments of the spine, as he would note certain misalignments secondary to the main region of primary complaint and diagnosis. But the choice of the CMT code was always based on the diagnosis, not his particular style or technique.
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