I sincerely hope to clarify with this two-part article the confusion regarding the correct usage of CPT code numbers (OMTs, CMTs, 97260, etc.) for reporting chiropractic adjustments (manipulations), the additional use of E&M codes (99201-99205; 99211-99215; 97250-97265) for office calls, and your ancillary procedure codes and rehabilitative exercise procedure codes.
There has been so much confusion and controversy perpetuated lately about the use of E&M codes and the new CMT codes vs. OMT codes by some non-chiropractic and DC entities who write articles and/or teach procedures and/or seminars. There have apparently been some confusing presentations and statements by some ACA presenters in Maine, Iowa, K.C., Wisconsin, among others.
As I stated in the past, the E&M codes (99211-99215) for established patients do not include the spinal adjustment (manipulation) procedure codes or ancillary codes. Some say they do, especially insurance companies and their DC consultants, but this is simply not true. This is not what is outlined and stated in the official AMA CPT '97 manual.
The E&M codes have seven specific factors. The 10 codes (five for new patients and five for established patients) have nothing to do with patient care codes. The spinal adjustments (97260, 97261, OMT, etc.) rehabilitative exercise procedures, physical therapeutics, and physical therapy codes are separate. All of these should be reported in addition to the E&M codes and the adjustment codes by utilizing proper CPT coding: 99212 (office call); 97012 (traction mechanical); 97035 (ultrasound); 97110 (therapeutic exercise -- 15 minutes); and 98926 (3-4 body regions- adjustment/manipulation).
Of course you must now use the CPT "CMT" codes if you are dealing with a Medicare patient. For example, 98941 (spinal, 3-4 body regions) implementation began Jan. 1 to April 1997 (please check with your local Medicare authorities).
I suggest you use the HCFA Medicare CMTs for Medicare patients "only" at this time. The following is a reprint from the AMA CPT '97 code book:
Chiropractic Manipulative Treatment
Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques.
The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional evaluation and management services may be reported separately using the modifier-25, if and only if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with the procedure.
For purposes of CMT, the five spinal regions referred to are: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joints); lumbar region; sacral region; and pelvic (sacroiliac joint) region. The five extraspinal regions referred to are: head (including temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities, rib cage (excluding costotransverse and costovertebral joints), and abdomen.
- 98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions
- 98941 spinal, three to four regions
- 98942 spinal, five regions
- 98943 extraspinal, one or more regions
Osteopathic Manipulative Treatment
Osteopathic manipulative treatment is a form of manual treatment applied by a physician to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of techniques.
Evaluation and management services may be reported separately, if and only if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with the procedure.
Body regions referred to are: head region; cervical region; thoracic region; lumbar region; sacral region; pelvic region; lower extremities; upper extremities; rib cage region; abdomen and viscera region.
- 98925 Osteopathic manipulative treatment (OMT); one to two body regions involved
- 98926 three to four body regions involved
- 98927 five to six body regions involved
- 98928 seven to eight body regions involved
- 98929 nine to ten body regions involved
Be advised that the term "physician," as per scope of practice in the individual states, is recognized by state and federal governments for DCs when treating state and county aid, workmens' compensation, and Medicare patients, using proper CPT codes. It is required to document one's clinical procedures and to accurately identify them.
The AMA CPT '97 code book on page iii states: Physicians current procedural terminology, fourth edition (CPT) is a listing of descriptive terms and identifying codes for reporting medical (generic term) services and procedures performed by physicians.
The purpose of the terminology is to provide a uniform language that will accurately describe medical (generic term), surgical and diagnostic services, and will provide an effective means for reliable and nationwide communication among patients, physicians, and third parties.
The introduction (page IX) of the '97 CPT states: "It is important to recognize that the listing of service(s) or procedure(s) and its coded number(s) in a specific area of this book does not restrict its use to any 'specific specialty group.'" Any specialty service in any section of this book may be used to designate the services rendered by a qualified physician. DCs are recognized as physicians as per their scope of practice by state federal laws and by participating in state and federally funded programs.
For clarification, today's DC and CA should follow two simple recommendations: Always remember there is a variance in state laws; and different types of patients have different contractual obligations, as do DCs participating in different programs.
I strongly suggest that all DCs and CAs check with their state board of examiners and/or their state chiropractic societies (associations) for any unusual and/or specific rules limited to geographical area and scope of practice.
Always remember, different types of patients (auto, workmens' compensation, Medicare, etc.) require different code numbers to report the same clinical services provided (i.e., adjustments, manipulations), and this may depend on the law, third-party contracts, or the participation agreements of the doctors.
Currently, in my opinion, there are at least six different ways to bill for spinal adjustments (manipulations), depending on patient classification and contract participation. The following six examples express my concerns the opinions:
I. Federal Patients
Federal patients (i.e., Medicare) historically have used the A2000. However, depending on your state contracted Medicare administrator (i.e., Blue Cross/Blue Shield, Travelers) you will be required in 1997 to use the new HCFA/CPT/Medicare CMT codes (98940-98942). Again, please be aware, Medicare laws will not allow for chiropractors to do extraspinal regions for reimbursement (i.e., 98943).
The '97 Medicare CMT codes will now further confuse issues by now including the conjunction skills of physicians for total work (pre-manipulation patient assessment services.)
Components of Physician's Total Work
Physician work includes the following:
- Time it takes to perform the service.
- Mental effort and judgment necessary with respect to the amount of clinical data that needs to be considered, the fund of knowledge required, the range of possible decisions, the number of factors considered in making a decision, and the degree of complexity of the interaction of these factors.
- Technical skill required with respect to knowledge, training, and actual experience to perform the service.
- Physical effort can be compared by dividing services into tasks and making the direct comparison of tasks. In making the comparison, it is necessary to show that the differences in physical effort are not reflected accurately by differences in time involved; if they are, considerations of physical effort amount to double counting of physician work in the service.
- Psychological stress -- Two kinds of psychological stress are usually associated with physician work. The first is the pressure involved when the outcome is heavily dependent upon skill and judgment and a mistake has serious consequences. The second is related to unpleasant conditions connected with the work that are not affected by skill or judgment. These circumstances would include situations with high rates of mortality or mobility regardless of the physician's skill or judgment, difficult patients or families, or physician physical discomfort. Of the two forms of stress, only the former is fully accepted as an aspect of work; many consider the latter to be highly variable function of physician personality.
Intensity often varies significantly in the course of furnishing a service. One common mistake is to anchor the value of the service to a point of maximum intensity during the service as the basis for comparing services. It is unlikely that the maximum intensity is an accurate reflection of the average intensity of a service; a lengthy procedure that is simple, except for a few moments of extreme intensity if probably less work than one of equal length during which a fairly high level of intensity is maintained throughout.
When using the old A2000 clinical procedure code (adjustments), it did not include this work (pre/post) as outlined by federal definition for the A2000. You could balance bill the patient for the normal office call. Also, for patients where you report the use of the 97260, 97261 codes or the OMT codes with the normal office calls, again, you bill these separately.
However, now appropriate 1997 E&M codes may only be reported for Medicare only in conjunction with the CMT codes whenever a medically necessary common distinct and separate service is needed above and beyond the usual pre-service and post-service work associated with the procedure. Obviously on a new patient encounter it would be appropriate to bill the patient an E&M code, along with the CMT code, if you treat on the first visit and other treatment procedures (i.e., ancillary procedures, physical therapy, rehab. exercise).
Some examples of when a Medicare CMT would be appropriate to utilize with the established patient E&M code with the CMT code, may be when a care re-assessment is performed: i.e., after the 12th visit; a long hiatus from care; a significant deterioration in patient's condition; or when re-assessment is needed to develop a new treatment plan because of an incident or accident.
Don't forget to have your written informed consent signed on all patients, and your Medicare waiver of liability forms signed (some states require every visit).
When an E&M code is billed for Medicare in conjunction with the Medicare CMT code, and only with a Medicare CMT code, a -25 modifier also should be used with the E&M code to indicate that a significant, separately identifiable evaluation and management E&M service by the same physician, performed on the same day as the CMT procedure, was done. Documentation and reporting should validate the necessary separate E&M service. It should be well documented in the doctors records. CMTs are for Medicare patients.
Now comes more confusion, but remember, "Conflicts clarify." It is this author's opinion that the '97 HCFA Medicare CMT codes which replace the Federal Medicare A2000 Code, should not be used on all patients. Only use on Medicare patients at this time.
There is also further confusion because under the federal Medicare rules (sections 2250, 2251.1, etc.) which state that all noncovered services are not to be billed to Medicare (i.e., 98943), including the normal office visits, lab tests, x-rays, physiotherapy, traction, etc.
How then are the pre/post work (call) included in the normal CMT without a federal law change? It is somewhat confusing because the current HCFA II approved Medicare CMT codes, according to the information from the ACA, is that pre/post service and manipulation is now under one code number, because Medicare CMT includes the pre-service and the post-services (office calls associated with the clinical procedures which are included in the new CMT codes). This conflicts with current federal sections 2250, 2251, 2251.1, etc., because the A2000 code for adjustments (manipulations) did not include the regular office call, unlike the '97 HCFA II Medicare CMT codes. The pre/post service for A2000 was (is) not allowed under the current federal regulations (section 2250, 2251, 2251.1, etc.).
This, in my opinion, is in direct conflict with what has been previously stated by the federal regulations, their administrators, and the information from the ICA and ACA. Information obtained from some Medicare, Medicare administrators and HCFA have stated that office calls (pre/post services) is a noncovered service by federal rule 2250, 2251, 2251.1, etc., along with exams, lab tests, x-rays, PT, etc., and now 98943 (extraspinal).
If you are using the HCFA II '97 Medicare CMT codes it now appears that your regular office call fee, which was previously balanced billed separately to Medicare patients, has somehow now been automatically calculated to either your 98940 (1-2 area region adjustments/manipulations, your 98941 (3-4 regions), or your 98942 (5 regions).
On the surface, it appears by billing these Medicare CMT codes you will be getting a raise. However, with the old Medicare A2000 you could balance bill your normal office call separately. So, by calculation, you are getting a raise, but you actually are not. Confusing.
Again, at first glance, the relative value unit (RVU) for the 98940 is .75. This is consistent with the values assigned to the old A2000. However, in my opinion, this still doesn't take into consideration that you could be fully compensated for the normal office call plus the A2000 manipulation. The RVU for the 98941 is .95. The RVU for the 98942 is 1.17. The RVU for the Medicare noncovered 98943 is .70. The RVUs were used in calculating reimbursement by using the RVRBS system. Medicare and many other third-party insurers now use this system rather than the old UCR system.
If you refer to the Physicians' Fee Reference and/or data management services Fee Facts, you will see that by utilizing the office call 99211-99215 (established patients), in addition to the old A2000, 97260, 97261, or OMT codes, you would be compensated at a higher rate than any of the current '97 Medicare CMT codes. Some third-parties now say that a DC "must" only use the Medicare CMT codes for billing all types of patients. This is not true.
Why do chiropractors always have to battle these issues "after" they become the new rules of the game? Who made these new rules? Did we have consensus on the new rules? Why in so many states with insurance equality laws are DCs not paid for office calls when MDs, DOs, PAs and PTs are?
To show these reductions, for general patients:
A) Take the 99212 (according to resources checked) which has an RVU at a .75, and the OMT for a 98926 (3-4 regions) which is 1.08. Combined, this would be a 1.83, compared to the Medicare CMT 98941 (3-4 regions) RVU, which is .95. You will lose RVU=.88 per visit for regular patients by using the Medicare CMT 98941 instead of using the 99212 and the 98926 RVU=1.83; or
B) If a 99212 is used and 97260 plus the 97261 X 3 (4 regions), which has an RVU=2.28 as opposed to Medicare CMT 98941 (.95), you will now lose 1.33; or
C) If you used a 99212 and the old A2000, RVU=1.70 as opposed to Medicare CMT 98941 (.95), you would lose again, RVU=.75.
Why? Who said DCs wanted separate Medicare CMT codes? What survey? What consensus? Instead, we should be informing HCFA with ACA/ICA and our legislative friends that we want to adopt the OMT codes plus office call(s), and be paid at parity with other providers using these codes.
I know someone will say, "HCFA said we must do this!" Remember, CMT is not required by law for all patients only '97 Medicare patients.
II State Aid Patients
State aid patients (i.e., Medicaid, general, county assistance, etc.) Some states have specific chiropractic codes that are only usable in those states (i.e., A2000 or X2010 after 18th visit), but not Medicare CMT. Some particular county assistance and general assistance programs in some states have their own chiropractic code numbers for tracking these types of patients in the computer.
III. State Workmens' Compensation Patients
Some states may have their own unique chiropractic codes, along with their own legislated limited fixed fee for services with care capitation levels (i.e., Maine, Michigan, Texas, Washington, etc.): not Medicare CMT.
IV. Individual Consideration/Contract Patients
Individual consideration/contract patients, or for those doctors who have cash practices, in-house contractual services, or personal PPO-HMO agreements, you may want to document your adjustments with the 97260 and 97261s, plus the office call and other procedures performed: Not Medicare CMT.
Check you state laws. You may have to post a bond or list your office as an in-house PPO or HMO. Also, any special financial consideration arrangement should be in writing using a written individual consideration (ICC). Any normal fee reductions should be documented with a financial hardship/concern affidavit stating the reduction and why.
V. Blue Cross/Blue Shield Patients
If you choose to participate with Blue Cross/Blue Shield (depends on what state you are in), they may have specific chiropractic codes for tracking their policyholders for spinal adjustments/manipulations: Not Medicare CMT.
In some states Blue Cross/Blue Shield is still adhering to the A2000 instead of Medicare CMTs. Blue Cross in some states, Texas, for one, is now seriously questioning the Medicare noncovered CMT 98943. They are questioning the 98943 usage and the DC training for extraspinal work that they may be asked to pay for.
VI. Auto Accidents, General Health and Personal Injury Patients
I would suggest you now use the E&M codes, along with the '97 OMT codes. These OMT codes specifically and correctly best describe what we do as DCs. As osteo means bone, and pathic means lesions, and the vertebral subluxation complex is a biomechanical lesion, this best describes how we address these diagnosed problems.
There may be some that have varying opinions regarding OMTs usage. In one particular state, an attorney general's office said that the OMT codes are illegal for use by non-osteopathic physicians.
This is ridiculous, especially based on the '97 CPT code book instructions and definitions. OMT usage "does not" require osteopathic training (check in your AMA CPT code book). I am not sure why our chiropractic training and philosophy should now get us reimbursed less.
Barry Eisenberg, director of the division of payment policy and programs for the American Medical Association, stated in a correspondence that it was not the intention of the CPT editorial panel to limit usage of the OMT codes for reporting purposes.
Instructions for CPT usage, clearly indicate that any procedures or service in any section of the book may be used to designate the services rendered by any qualified physician DCs are physicians.
K.S.J. Murkowski, DC
645 St. Clair Ave.
Jackson, MI 49202