Multimodal chiropractic is an increasingly popular, expansive therapeutic approach of lifestyle, nutrition, modalities, and active care that augments CMT. These days, patients expect a rapid response and embrace new and trending approaches to help them achieve excellent outcomes. Modalities such as TECAR, laser, shockwave, and vibration all accelerate pain relief and healing of soft tissue. Exercise is essential, but handing your patient a list of generic exercises to take home is not the experience patients want today.
Incorporating a multimodal approach is expensive when you purchase new modalities, but incorporating an effective new technology into your practice is a win-win: The patient gets the experience and outcome they desire, and you get an additional income generator.
That's right, multimodal care is both patient centered and profitable – something we all need in the current economic environment. So, let's get real and break down how to take a trending modality, whole-body vibration (WBV), as an example, and address implementation and compensation. (Note: I addressed the science and application of WBV in my last column – February 2023 issue.)
Outlining an Example: LIV
The benefits and safety of low-intensity vibration (LIV) for osteoporosis and sarcopenia are well-established; however, research also shows it improves balance, muscle reaction time, circulation and neuromuscular control. Here is the multimodal approach:
CMT provides correction of spinal and extraspinal imbalances. We understand that chiropractic adjustments "reboot" the nervous system. Therefore, stacking LIV after every visit on every patient, regardless of your practice style, will enable their adjustments to sustain longer because it stimulates the nerves while building muscle and bone.
Billing Tip: LIV is user independent: the patient just stands on the plate for 10 minutes. If your office is busy and there is limited availability for a provider to have one-on-one contact with the patient during the LIV session, it is a cash service. Remember, Leung found LIV beneficial for osteoporosis after 18 months, 5x/week. Not a bad income generator, even at $5/session.
Postural Correction
If you address postural correction, LIV is the perfect tool to help your patients develop the endurance needed to stay in tall, strong posture in everyday life. Standing on the platform in neutral spine, core engaged, feet aligned with strong arches (Janda's short foot) for 10 minutes sets them exactly where they need to be. Upper-body exercises with light weights (3 lbs or less) improve the transmission of the vibration into the upper body, too.
However, to be effective, this requires direct one-on-one doctor-patient interaction while on the platform. Cueing is needed to make them aware of every aspect of the correction taking place; and to create endurance of the targeted muscles.
Billing Tip: By definition, therapeutic procedure (CPT 97110), one or more areas, each 15 minutes is therapeutic exercise to develop strength, endurance, range of motion or flexibility. It is billed based on the therapeutic goal, not the procedure used, and your documentation must show objective loss of joint motion, strength or mobility. As with all timed codes, it requires direct one-on-one contact with the provider. If you can meet these requirements, then LIV can be billed as 97110.
Balance / Fall Prevention
Fall prevention is essential for everyone, especially the elderly. Balance issues are prevalent and arise from numerous issues that include deconditioning, weak posture (thoracic kyphosis, forward head posture, pelvic obliquity), visual and vestibular impairment and neuropathy. Sensorimotor testing is a simple, quantifiable assessment tool which documents the need for balance rehabilitation. It can also be used to screen for core, lower-extremity and vertebrobasilar rehabilitation.
If a patient fails sensorimotor testing (they are unable to stand on one leg with their eyes open for 20 seconds or with their eyes closed for 10 seconds), it is appropriate to prescribe a balance program. (For a tear sheet on performing sensorimotor testing, email me.) At that point, you can treat them in your own office, send them for PT or recommend an online remote course, or.
Consider providing a "balance class" as a cash service (they would pay for a YMCA membership anyway) or if you are the instructor, it can be billed as a group therapeutic procedure (CPT 97530) for your patients. Group therapy (97530) is billed in 15-minute increments, does require constant attendance of the physician or therapist, but does not require one-on-one patient contact by the provider.
Teaching a group exercise class not your thing? Then simply put them on the LIV platform, since it has been shown to improve balance and neuromuscular control. Then the billing code for neuromuscular re-education (97112) may be appropriate.
Billing Tip: Neuromuscular re-education (97112) is another timed code that requires direct one-on-one contact with the provider. Essentially an OT code, it is used when a patient requires re-education of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing activities. Therefore, if a patient fails sensorimotor testing, standing on the LIV platform, with direct one-on-one contact for the minimum time, can be billed as 97112. (By the way, this code also requires a -59 modifier.)
Active Care
Active care integration is currently considered a standard of care in chiropractic. However, most patients do not perform their exercises outside the office; therefore, we need them to exercise in the office. In addition, as you oversee the exercises you can cue the patient to performing in proper alignment (which is expressly what is not happening at the gym or with their personal trainer), underscoring the benefit of chiropractic rehabilitation.
Remember, when billing for active care there is a time requirement of direct one-on-one patient contact with the provider. Being in the same room does not fit that criteria. Giving an adjustment is direct one-on-one contact. Giving exercise instructions across the room is not.
Take-Home Points
The codes listed in this article apply to the intended therapeutic goal, not the device used. LIV is only one example. I use it because it is safe for all age groups and conditions, and fits into my practice seamlessly.
Finally, even if you are billing a cash service, still document the intended goal and outcome in the patient's file.
Multimodal chiropractic incorporates all aspects of the chiropractic paradigm: lifestyle, exercise, CMT, nutrition and emotional well-being. Understanding the science behind every modality, technique, exercise and supplement you recommend is essential to get the best outcomes; but at the end of the day, our offices need to be profitable, and a multimodal approach provides numerous revenue streams.
Editors Note: Per the author, the aforementioned recommendations are guidelines only. Check local and state regulations to ensure you are practicing within the laws in your state. "Creative billing" that is in a gray area or simply inappropriate is not worth your license.
Resources
- CPT 2022 Professional Edition. American Medical Association, 2022.
- Gilsanz V, et al. Low-level, high-frequency mechanical signals enhance musculoskeletal development of young women with low BMD. J Bone Min Res, 2006;21:9.
- Hawk C, Schneider MJ, Haas M, et al. Best practices for chiropractic care for older adults: a systematic review and consensus update. JMPT, 2017 May;40(4):217-229.
- MarÃn-Cascales,E, et al. Whole-body vibration training and bone health in postmenopausal women: a systematic review and meta-analysis. Medicine, 2018;97:34.
- Muir J, Kiel DP, Rubin CT. Safety and severity of accelerations delivered from whole body vibration exercise devices to standing adults. J Sci Med Sport, 2013 Nov;16(6):526-31.
- Pagnotti GM. Review article: Suppression of cancer-associated bone loss through dynamic mechanical loading. Bone, 2021;50:115998.
- Rajapakse, CS, Leonard MB, Kobe EA, et al. The efficacy of low-intensity vibration to improve bone health in patients with end-stage renal disease is highly dependent on compliance and muscle response. Acad Radiol, 2017 Nov;24(11).
- Rubin C, et al. Transmissibility of 15-Hertz to 35-Hertz vibrations to the human hip and lumbar spine: determining the physiologic feasibility of delivering low-level anabolic mechanical stimuli to skeletal regions at greatest risk of fracture because of osteoporosis. Spine, 2003;28:23.
- Stania M, et al. The application of whole-body vibration in physiotherapy – a narrative review. Physio Int, 2016;103(2).
