QUESTION: I am a provider for VA Choice and have received several referrals. However, I am not being paid for any services other than exams and manipulation. None of my physical medicine codes is being paid, and the explanation of benefits indicates there is a missing or incomplete code or modifier. What am I doing wrong?
The VA Choice Program (PC3 as well) indeed pays for chiropractic care including manipulation (CMT 98940-98943) and some physical medicine services. The standard episode of care (SEOC) for doctors of chiropractic under VA Choice allows 12 visits for 365 days including an initial evaluation and management (E&M) service, as well as re-exams as needed. Any necessary radiologic evaluation for the referred condition is also allowed.
The coding and billing for E&M are standard as you would do for any insurance, meaning using the new-patient 99201-99205 or established-patient 99211-99215 codes. Billing of these codes requires appending with modifier 25, assuming a CMT or other treatment is billed on the same date. The 25 modifier is needed, of course, to demonstrate the exam was above and beyond the day-to-day preservice and postservice evaluation associated with treatment. No special modifier beyond modifier 25 is needed to have the service paid.
For chiropractic, manipulation billing and coding is also standard with no modifiers necessary. But as with any claim for CMT, the code does need to match the number of regions of diagnosis, as well as the regions manipulated.
Nonpayment for Physical Medicine: Another Case of the Missing Modifier
Now to your question on nonpayment of physical medicine, which is due to not having the proper modifier. The modifier is unique to the VA and other federal claims including Medicare. The modifier needed for all physical medicine codes is GP. This modifier is used to indicate there is a physical medicine plan of service; without the modifier, the physical medicine code will be denied as missing or incomplete.
All of your physical medicine services, whether massage 97124 or manual therapy 97140, will need modifier GP in addition to the standard modifier for those services (59). Please note the order of the modifiers does not matter (GP 59 or 59 GP). Also note that the SEOC is for those two physical medicine codes only; no other services such as exercise, ultrasound, electrical therapies, etc., are approved.
Additional PM Services / Visits
Any additional physical medicine services will require an additional request to perform by demonstrating a need and efficacy. As a general rule, I recommend performing per the SEOC and if additional care is needed, make the request after the first 12 visits.
It is not uncommon to have additional visits authorized, although bear in mind the SEOC specifically indicates chiropractic care justification must include a detailed plan with specific timeline linked to objective measurable improvement. The following expectations apply:
- Significant decrease in pain intensity
- Functional improvement demonstrated by clinically meaningful improvement in validated disease-specific outcomes instruments; return to work; and/or documented improvement in activities of daily living
- Documented decrease in utilization of pain-related medications
It is highly advisable to use true validated outcome tools such as Oswestry, Neck Disability Index, DASH, etc., to more readily demonstrate functional improvement. Also, pain scales should be focused on a function related to the level of pain – not simply a perception of the pain at its worst, but how it affects the patient's ability to perform daily activities.
VA Choice: A Good Choice for DCs
VA Choice is clearly the opportunity for the chiropractic profession to provide care to a group of patients who often are relegated to pain medication only. It also provides a chance for chiropractic to have an accounting of the value of its services, creating a data set that should demonstrate the efficacy and cost reduction for patients receiving this integrated and complementary care plan.
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