Does # of Services Raise a Red Flag With Insurers?

QUESTION: Are there any limits as to the number of services I can provide per visit? I often use physical medicine services as an adjunct to my chiropractic manipulative treatment and do not want to create a "red flag" on my claims.

This question is not uncommon and poses an interesting dilemma to providers when choosing care for their patients and how that care is reflected in the billing and charges. Care plans should, of course, be based on the condition of the patient, along with any complications or comorbidities that may affect or inhibit recovery.

One should, in addition to using their own experience, also be aware of what "evidence-based" protocols are available, as those are good starting points. Bear in mind guidelines are just that and are not considered so rigid that care plans cannot differ; but this difference should have some valid reasons and protocol. Within these guidelines, there are predictions as to length, frequency and types of care. This care generally can be defined as the acute and active phases of care, and where each specific service fits in each phase.

For instance, in addition to chiropractic spinal manipulation, other modalities, both passive and active, are often used as adjunct treatments. Passive modalities include treatments such as electrical stimulation, therapeutic ultrasound, therapeutic heat, cryotherapy, traction, diathermy, and massage. Passive modalities are most effective during the acute phases of care, as they are typically used to reduce pain and swelling. They may also be effective during the acute phase of an exacerbation of a chronic condition.

Passive Modalities

Let's deal with the typical and expected passive services first. According to the chiropractic policy provisions adopted by major carriers such as Aetna, BCBS and Cigna Chiropractic:

"Most uncomplicated cases can be adequately managed with spinal manipulation plus one or two adjunct modalities. Using more than two to three adjunctive passive modalities in one visit, in addition to joint manipulation, is considered excessive and not of proven benefit."

Based on this statement, as far as passive services are concerned, no more than two to three per visit are allowed. Considering that passive services essentially have the same goal, multiple modalities to the same region would likely be considered redundant, excessive and expressing no specific separate purpose.

That said, there may be instances in which one passive modality may have better efficacy in one region, while a separate service may better benefit another region, which could lead to multiple passive services. For instance, you might apply a CMT to the spine, but for the cervical spine apply electrical stimulation to reduce pain, spasm and inflammation, and provide massage to the lumbar spine.

Be sure your treatment and goals distinguish the separate parameters and needs for the region and the necessity for multiple (in the above example, three) passive services. Be direct and mindful to document when more than one passive service is directed to a specific region, and that there is a clear rationale and stand-alone purpose for each modality, with no overlap. While not impossible, it generally would not be plausible in most instances.

Additionally, treatment plans for patients who are at risk for developing chronic conditions should de-emphasize passive care and focus instead on active care approaches. This does not limit the number of services or units, but does relate to the length of the necessity of the passive services and when they have achieved desired goals – often within 2-4 weeks.

Active Modalities

Another scenario to ponder is multiple units of an active therapy, such as therapeutic exercises 97110, therapeutic activities 97530 or neuromuscular re-education 97112. Often to achieve the desired result of this rehabilitation, a single unit is not sufficient to stimulate proper adaptation.

The active phase of care implies that when 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. Certainly, most PT therapy protocols often provide 2-4 units of these active services. But although multiple units of the service are being provided, it is still only one therapy.

Practical Applications

Based on most common neuromusculoskeletal conditions seen in a chiropractic setting, the average treatment plan would fall into spinal manipulation plus one to two adjunctive therapies. Ultimately I would not be concerned with a specific number of services, but more on the goals of each service and that each service has its own stand-alone goal(s) and purpose. Nonetheless, there should be attention to the details of each to ensure there is a rationale and that it is clearly identified in the care plan.

I would particularly pay attention to the use of passive modalities when more than one is used and/or is done for extended periods. Active therapy may and likely will encompass only one code, but can have multiple units based on the level of rehabilitation and adaptation. Although multiple services may create a red flag, it is my experience that more often it is length of care that raises questions about treatment effectiveness. There should be a tapering of visits and services with added home protocols as the patient progresses.

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Editor's Note: Feel free to submit billing questions to Mr. Collins at sam@hjrossnetwork.com. Your question may be the subject of a future column.