Q: I have a patient who had an injury to her lower back and was under care. After one week of treatment, she hurt her neck in an auto accident. She had no additional complaints to her lower back as a result of the accident, but still needs care for that condition. Can I bill my chiropractic adjustment code 98940 in full to both insurance carriers? I have one colleague who says I can, but another says that if I do, it would be "double-dipping."
A: You must split the billing for the chiropractic manipulative therapy (CMT). The codes for CMT are chosen based on the number of regions diagnosed and treated. In this case, it is the lumbar and cervical regions. Therefore, the appropriate code for chiropractic would be 98940, which is the code used for one or two regions. You would bill the code 98940 with modifier -52 to each carrier and reduce the fee 50 percent. This modifier is to designate a lesser or reduced service. In this case, the reduced service is the adjustment, as it is being applied to two separate regions and each region has a different responsible party. Accordingly, each party is responsible for their portion, but in the end, you still receive the full amount for the service provided.
Your colleague who told you it would be "double-dipping" was absolutely correct. If you were to bill in full to both, it would be inappropriate. The CMT service includes one or two regions, and payment in full from both would constitute a duplication of payment. When you do have a case like this, it is imperative to notify each carrier of the dual injury, the purpose of the modifier, as well as the reduced fee on the specific service code. A simple explanation attached to the claim is sufficient.
Further, any services that are done to both regions would be split in the same fashion, which may include evaluation and management services. But, for a service done to one region and not the other, that specific service may be billed in full without any modifier. For example, if there was a chiropractic adjustment in the cervical spine with the application of electrical stimulation, and a chiropractic adjustment with ultrasound in the lumbar spine. In this scenario, the CMT is split as discussed previously, but the electrical stimulation would be specifically billed to the party responsible for the cervical injury and the ultrasound to the party responsible for the lumbar injury.
Should one of the regions of injury resolve and care for the other, then the billing would be 100 percent the responsibility of that single party and all services would be billed in full to that party alone.
I have certainly found that it is typical to not understand how this billing in a dual-injury scenario should be done correctly, as it is tempting (or at least seemingly reasonable) to bill in full to both parties. In fact, most providers assume that you can bill in full to both parties. This mistake is quite common, even though not intentional. But the assumption is not correct and as a consequence, I get inquiries several times per year from attorneys seeking aid in defending a client who is being accused of overbilling and/or committing fraud for this specific scenario.
Please take heed of the proper way to bill for this situation and avoid problems. Dual injuries will not increase payment on a per visit basis, generally, but might increase the overall need for and length of care.
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