Billing for Same-Day Visits and Medicare Documentation

Q: What would be the proper way to bill for a patient who is seen twice in one day, during which he received a chiropractic manipulation on both visits, but electrical stimulation only on the first visit?

A: When billing for a second service on the same day, the procedure or service that was repeated will be coded a second time, but with the modifier -76. This modifier is used to indicate that a procedure or service was repeated subsequent to the original service. Therefore, you would bill one CMT service without any modifier, and a second CMT with the modifier -76 (98940-76). The billing for electrical stimulation (97014) would not require any modifier. While this type of repeated service may be useful, it's not typical and might be prone to nonpayment. Therefore, a sound medical rationale is needed and should be done in as concise and objective a manner as possible, in the form of a short letter or report included with the billing.

Medicare Documentation Requirements

Due to the many questions I have received on Medicare documentation, I am providing the Medicare (CMS) requirements for chart-note documentation below. When documenting care, always have in mind that Medicare (or any insurance carrier, for that matter) is looking for objective and functional changes as a result of care.

On Initial Visit

A. History: History should include: symptoms causing patient to seek treatment; family history (if relevant); past health history (general health, prior illness, injuries or hospitalizations, medications, surgical history); mechanism of trauma; quality and character of symptoms/problem; onset, duration, intensity, frequency, location and radiation of symptoms; aggravating or relieving factors; and prior interventions, treatments, medications and secondary complaints.

B. Description of the present illness, including: mechanism of trauma; quality and character of symptoms/problem; onset, duration, intensity, frequency, location and radiation of symptoms; aggravating or relieving factors; prior interventions, treatments, medications and secondary complaints; and symptoms causing patient to seek treatment. (Note: Symptoms should bear a direct relationship to the level of subluxation.)

C. Evaluation of musculoskeletal/nervous system through physical examination.

D. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms might refer either to the condition of the spinal joint involved, or to the direction of position assumed by the particular bone named.

E. Treatment plan: The treatment plan should include the following:

• recommended level of care (duration as well as frequency of visits);
• specific treatment goals;
• objective measures to evaluate treatment effectiveness.

F. Date of the initial treatment.

On Subsequent Visits

The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination.

A. History:

• review of chief complaint;
• changes since last visit;
• system review (if relevant).

B. Physical examination:

• exam of area of spine involved in diagnosis;
• assessment of change in patient condition since last visit;
• evaluation of treatment effectiveness.

C. Documentation of the treatment provided on day of office visit.