Q: I have noticed a trend for medical necessity of chiropractic services to be defined with statements and language indicating "functional improvement" as one of the standards for efficacy of treatment.
A: I also have seen this same statement of medical necessity for "functional change" as a parameter. For example, Cigna Insurance defines medical necessity in its Chiropractic Policy 0267 with the following statement: "demonstrated progress toward significant functional gains and/or improved activity tolerances." Even Medicare (CMS), in its coverage guideline for chiropractic, states a similar protocol: "A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as in the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement."
Functional change often can be demonstrated simply with details of improvement in activities of daily living. However, this type of subjective measure, though positive, may lack objective validity for care beyond the short term. The importance of an assessment is to have a measure that can be used repeatedly over the course of treatment to demonstrate improvement or maintenance of function that would otherwise deteriorate. Objective measures of functional performance in the clinic (e.g., "Able to lift 10 lbs. floor to waist, 5 repetitions") is preferred, but may include assessment of functional status through the use of questionnaires and pain scales (Oswestry, VAS, etc.).
97750: When to Use It
Clearly, a measure that is objective and can be repeated is superior. This is where it may reasonable, in some instances, to code for functional testing and measurement. Consider the physical medicine and rehabilitation code 97750, Physical Performance Test or Measurement (e.g., musculoskeletal, functional capacity) with written report, each 15 minutes. This can be used for functional performance tests to assess current deficits and needs, and identify problems.
This service requires documentation of the specific test used, description of the data collected and the implication on the patient's plan of care, as well as decisions made based on the results. Successful use of this code requires a post-test report, along with discussion of how the results of the testing will impact the treatment plan. Per the December 2003 CPT Assistant, "CPT 97750 is intended to focus on patient performance of a specific activity or group of activities," so it is not limited to one test, but can be a battery of functional tests specific the patient's condition and disability.
Examples of such tests include, but are not limited to, static back endurance, squatting, horizontal side bridge, one-leg standing, repetitive sit-up, timed up and go, Tinetti, Berg balance, etc. Ultimately, intent is a measurement to determine functional loss, as well as to validate the patient's progress in therapy.
Restrictions / Contraindications
Billing guidelines recommend using this code no more than one time per month, though some plans and necessity may require every two weeks. Generally, this testing is conducted at the beginning of the treatment to establish baseline levels of function, at the middle of treatment to evaluate progress, and at discharge to determine post-treatment status. As mentioned, successful use of this code requires a post-test report, along with discussion of how the results of the testing will impact the treatment plan.
There are only 482 ICD-9 diagnosis codes that can serve as medical necessity for 97750 code use; i.e., you must link a valid ICD-9 code to 97750 on the HCFA-1500 form (box 24).
Note: Valid ICD-9 codes only include 711.xx – 729.xx, which do not include sprains / strains, ligament or meniscus tears, or fractures. Those conditions may be part of the diagnoses; however, there must be a neuromusculoskeletal ICD-9 code in the 711-729 range. If not, the computer reviewing your claim may automatically reject it.
These services are not to be used in lieu of evaluation or re-evaluation services, but are separate and distinct. They also are not bundled into the evaluation and management codes 99201 to 99215. 97750 does not bundle with physical medicine and rehabilitation codes, nor does it bundle with chiropractic manipulative therapy. 97750 also is to be used when billing for physical performance tests / measurements that are required by the treating physician in preparing an impairment rating.
Do not use 97750 for range-of-motion or muscle testing; codes from this series (95831-95852) would be appropriate if you're only doing a muscle test or range-of-motion measurement. It is also not applicable to bill 97750 when doing a computerized gait evaluation to fit a patient for orthotics. These tests generally do not involve a detailed analysis of the patient's functional status.
Also note that 97750 is a 15-minute code and the eight-minute rule applies, as it does to all timed physical medicine services. The provider of service must be physically present during the entire length of the tests; any testing not done face-to-face is not billable.
Take-Home Points
It is definitely possible to code and be reimbursed for specific functional performance testing. I recommend a standardized or consistent protocol for measuring function regarding the common areas you diagnose and treat (likely the neck, trunk, upper and lower extremities). Identify the specific tests with the number of repetitions and or resistance performed. If possible, the tests should have a median level of function so you are not only measuring where the patient is, but also establishing a clear goal or level of expectation.
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