Billing for Modalities

Q: I am concerned about billing for modalities, as they seem more likely to be denied than paid. What can I do to get paid, and is there something else I should be doing to help the process?

A: You are certainly seeing what many others are seeing - a decided utilization protocol that denies modalities or limits payment. As far as the billing of modalities goes, I would assume that as long as you are billing with the correct codes (97010-97028 for unattended and 97032-97036 for attended) that your billing is correct.

For the unattended services, they may be billed only once per visit, regardless of the time spent or number of regions of application. For the attended type, services may billed in units based on the amount of total time spent. However, it is not the billing that is likely the specific reason for denial, but rather the necessity of such services being performed. Here is an excerpt from CIGNA's position on chiropractic that addresses active and passive protocols:

"Passive modalities include treatments such as electrical stimulation, therapeutic ultrasound, high-voltage galvanic stimulation, therapeutic heat, cryotherapy, passive assistive exercise, traction, diathermy and massage. Passive modalities are most effective during the acute phase of treatment, as they are typically directed at reducing pain and swelling."

Note the emphasis on the effectiveness is in the acute phase. Therefore, if passive modalities are done beyond the acute time frame (likely no more than the first four weeks following an injury), the incidence of denial is likely to be higher.

CIGNA further states: "They (passive modalities) may also be used during the acute phase of an exacerbation of a chronic condition. The optimal duration of a course of passive modalities is a maximum of 1-2 months, after which their effectiveness diminishes, and patient dependency may develop." I have noted that carriers are denying not only for long-term use, but also for multiple modalities, which they see as duplicative and not medically necessary.

"Most uncomplicated cases can be adequately managed with spinal manipulation plus one or two adjunct modalities. Using more than 2-3 adjunctive passive modalities in one visit, in addition to joint manipulation, is considered excessive and not of proven benefit." Based on these guidelines from CIGNA and very similar positions by Blue Cross Blue Shield, Aetna, et al., it is clear that the rationale and goals for use of passive modalities are being challenged.

The basic purpose of most modalities falls into three classes: reduce pain, reduce spasm and increase circulation (inflammation). Consequently, multiple modalities that are applied to the same body region would be hard to defend as separately medically necessary in addition to prolonged use. Carriers are consistent in noting that long-term or prolonged use of passive modalities may or will cause patient dependence.

However, there is more that you should be looking to do; after all, the goal of care is not simply to reduce pain, but also to effectuate some functional improvement. CIGNA offers the following in its guidelines:

"As swelling and inflammation are reduced, the need for stabilization and support is replaced by the need to increase range of motion and restore function. Active modalities include increasing range of motion, strengthening primary and secondary stabilizers of a given region, and increasing endurance capabilities of the muscles. Active modalities focus on patients' active participation in their exercise programs. Progressive resistive exercises are considered an active modality."

Based on the above, it is fairly clear that passive care may and should encompass the early stages of care, but a transition to active care should be made as soon as is reasonable and can be tolerated by the patient. Active care is considered more effective in restoring functional improvement and to reach pre-injury status. And keep in mind that from a billing standpoint, active services are of a higher value than passive services.