Giving it Away….What Services Should You Be Billing, But Aren’t?

There is a fine line that exists between the charity of giving and the lack of value placed on your services.  In this day of limited or lack of insurance coverage for more and more of our services, we certainly have to think more about it now than ever before.  However, in my years of service in this chiropractic industry, the one truth that resonates most loudly in my ears is:  “What patients pay for, they value.  What they get for free, they’ll take for granted, and then demand as a right”. 

As I talk to doctors around the country in seminar and one on one, I find that the biggest concern is how to blend proper and accurate coding with affordability for the patient.  Doctors want to code and document correctly.  But the biggest deficiency I find when auditing charts is that the services rendered and documented in the daily notes are not congruent with the codes chosen for that day.  Everything must jive, from the proper diagnosis to the correct linking of the procedure code to the diagnosis code. And for those patients who are uninsured or underinsured, check out a great cash discount network, like HealthNet USA. It’s the best way to go.
 

These are three examples of codes that many doctors are performing and not charging for. 

1)       Extra spinal manipulation, 98943

When the Chiropractic Manipulative Treatment (CMT) codes were implemented in 1997, four codes entered into our world.  The coding authorities that created these codes felt it was important that spinal manipulation was not the only service represented in chiropractic coding.  Extra spinal manipulation was also  introduced and  includes five regions: 

·         Head:  includes head and TMJ but not the atlanto-occipital joint

·         Lower extremities: includes the hip, leg, knee, ankle, and foot

·         Upper extremities: includes the shoulder, arm, elbow, wrist, and hand.

·         Rib cage: anterior ribs, including the costosternal junction

·         Abdomen

When performed on the same date as a manipulation, there are some companies that still require the -51 modifier to indicate that it’s been performed along with the spinal adjustment.  There is a work value crossover since the spinal and extra spinal manipulations are in the same code family. 

            The interesting concept here is that doctors of chiropractic are fully entitled to bill for both manipulations when performed if medically necessary.  However, file audits show that only 57% of doctors bill for the extra spinal manipulations.  One reason is that “where much is given, much is required”. To bill for extra spinal manipulations and justify with medical necessity there must be a correlation between the extra spinal symptoms and the examination findings.  There should be a treatment plan that includes the extra spinal manipulation and a diagnosis for this area.  The daily notes when the extra spinal manipulation is performed should reflect the necessity for that treatment on that that visit.  However, the “much is given” part makes this well worth it.  The Relative Value Unit (RVU) or value of this 98943 code is approximately between the value of your 98940, CMT 1-2 areas and your 98941, CMT 3-4 areas.  This makes this extra effort well worth your time.  It is typically a well reimbursed code.  However, well documented medical necessity is essential. 

2)       Rehabilitative exercise codes, 97110, 97530, and 97112

One of the most beneficial services, after the Chiropractic manipulation, that a doctor of chiropractic can render to a patient is low or high tech rehabilitation.  Not only does this allow chiropractors to fully participate in the mainstream of healthcare, but it makes it possible for them to become proficient in objectively assessing and documenting the functional outcomes of their care, which helps establish medical necessity.  Very simply put, the best investment that can be made is to include simple low tech type equipment, such as gymnic balls, both large and small, wall mounted tubing and resistance equipment, and bands.  High tech weight stack equipment further enhances a practice’s ability to provide these services.

Many practices do these now, and simply don’t charge for them.  Again, one reason is that they may not be practicing with a standard of care based on evidence and well documenting functional improvement.  As chiropractors, we know that active care and stretching and strengthening are an important part of the functional restoration process.  However, many doctors will provide these exercises on a sheet of paper with home instructions and that’s the end of it.  Evidence proves that patient compliance goes up when supervised rehabilitation is initiated in the practice.  Amazingly, many insurance carriers now pay better for these services than they do for manipulation.  Some managed care companies will require that active care be included in the treatment plan or no pre-authorization will be granted. 

When exercises for stretching and strengthening are prescribed as part of your treatment plan, consider adding them to the office visit with supervision.  There are a variety of codes, 97110, Therapeutic Exercise, 97530, Therapeutic Activities, and 97112, Neuromuscular reeducation.  Based on the context of the service you are providing, any of these codes may be applicable.  Chances are you’re doing some of these services anyway and simply not billing for them.  When you add them to your treatment plan, not only does it help to document functional improvement, it will also surprise you how well covered these codes are when justified with medical necessity.

3)       Non-covered, non-coded services

 
    There are many services rendered now in chiropractic offices that have no specific codes or values assigned through the CPT^© coding process.  Some of these services include decompression therapy, hydrobed massage, cold laser, and others.  Just because there is not a code assigned, doesn’t mean that you should not be billing these as a cash service. Anyone with any kind of decompression table is aware of the amazing results obtained with patients. Regardless of what is being told by manufacturers, there is no valid CPT^© code for this service.  The most accurate code you can            use is a non-specific code like 97039 which is an unlisted modality, or 97139 which is also an unlisted procedure.  If you are going to bill an insurer for any of these services, you must use these codes.  However, it is expected that you will be billing the patient for these “cash” services.  It’s reasonable that any treatment plan that includes decompression, cold laser, or other such services, will also include a cash payment plan for these services.  Again, what a patient is given for free has no value.

After 26 years in this profession, I’m convinced that “value is in the eye of the beholder”.  Patients of our early ancestor chiropractors paid with a dozen eggs, a few dollars or whatever they had.  I believe patients will always see chiropractic for the value that it is and will find some way to pay for the care.  Don’t be afraid to value your service and charge for what you do.  The results that are achieved through chiropractic care are invaluable to a patient.  Don’t do a disservice to them and to yourself by devaluing your services by giving them away. 

Kathy Mills Chang has been a chiropractic professional for more than 26 years, working in the areas of reimbursement and financial matters.  She is the founder of her own chiropractic consulting firm with concentration on helping doctors make and keep more money. She teaches hundreds of seminars around the country on documentation, coding, and other financial matters. She can be reached through her website at www.kathymillschang.com or via email at Kathy@kathymillschang.com.

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