Samuel A. Collins
Q: Is there a maximum amount of units for a single service or maximum number of services that can be billed in one visit?
A: While there is no set law prohibiting or limiting the number of units of a specific service, and no maximum number of services that can be billed for a given visit, there certainly is the factor of what is reasonable and/or medically necessary.
One facet that determines the efficacy of codes to be billed is the Correct Coding Initiative Edits (CCI Edits). While these are designed to deal with bundling of code issues, they certainly give direction as to what codes should or should not be reimbursed when done in the same visit. The most common example is the use of Manual Therapy 97140 when done on the same visit as Chiropractic Manipulative Therapy 98940-98943. These CCI Edits dictate the codes are not to be separately reimbursed unless performed to a separate region of the body.
But to address your question more directly, it has been my experience that billing for chiropractic services which include physical medicine procedures that go beyond three separate physical medicine services (codes) are more prone to denials, or at least a request for additional information before any reimbursement is made. Notice this does not state the care was not necessary or should not be paid, but solely that it will get more scrutiny. In speaking to others in the chiropractic profession, there are those who believe any services beyond two therapies in addition to the manipulation service will be "red flagged."
Therefore, if billing for more than two procedures, it's imperative to be sure that documentation clearly identifies the specific needs and goals of each therapy. If a service cannot demonstrate to have its own "stand-alone" value, the risk of denial is high. Further services must be distinct in what they are set to accomplish. Particularly, multiple modalities in a single visit may be denied, as the services may be deemed duplicative in nature. Note that most modalities are used to reduce inflammation, reduce spasm, increase circulation, reduce pain; therefore, practitioners utilizing multiple types to accomplish the same goal(s) would be hard-pressed to indicate the separate nature and need for each one separately. But it is possible; consider the use of two forms of heat on the same visit, if the goals are to affect both deep and superficial structures, with one heat being superficial and the other deep. Obviously, the condition and diagnoses would indicate such a need. American Chiropractic Network (ACN), which is now doing reviews of chiropractic claims for many payers, pays special attention to multiple modalities and likely is to deny without explanation, as it focuses on the duplicative nature of modalities.
The same parameters apply to codes and procedures that involve time. For example, Massage 97124 is a 15-minute code. Therefore, if one hour of massage is provided, the code would be billed for four units. But are four units reasonable for the condition and diagnosis? If the diagnosis were cervical spine only, four units would appear to be unreasonable simply based on the size of the region, as it would be hard to reason that one hour was spent massaging the cervical spine. Therefore, carriers likely will assume the massage might have or also was performed to unrelated areas and, as such, is not medically necessary. Again, the use of this amount might be appropriate if there is proper documentation of need, based on the specific regions affected by the diagnoses.
Please do not construe this answer as any indictment of use of any code(s), service(s) or their amount. It is an issue of practicality. Like most things in life, if it appears unreasonable from the outside, it most likely is, unless documented otherwise. I believe chiropractic is one of the most effective forms of health care and I hope the profession continues to lead the health care industry, not only in terms of overall outcome but also with regard to efficacy.
Note: In some states, such as California, the workers' compensation system limits each visit to two hands-on procedures and two modalities. However, this rule is specific to workers' compensation claims only.
