The Modifier Maze: Tips and information concerning the modifiers we use in billing, what they mean and how they can be used for maximum reimbursement.

Insurance Billing and Counseling:  Here you will find a few facts concerning billing Report of Findings and Counseling.

Chiropractic Billing and Physical Therapy:  Are you leaving money on the table? Providing Physical Therapy to your patients increases their chances of staying healthy while adding more income to your practice.

Medicare and the ABN: A simple guide to the ABN rules along with a downloadable and editable ABN form for your use.

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The use of modifiers in insurance billing confuses many doctors and billers --- what modifier to use as well as when to use it.  I have known many providers to make the same mistake:  Put a modifier on the code, just to be safe!  Well, sometimes adding a modifier without really knowing WHY can get you your payments, but if you do not document your areas of work, you could be in a lot of trouble come auditing day! chiropractic billing medical billing


25:     This is the Evaluation and Management modifier, E/M.  This modifier is used when your evaluation is not a part of the normal beginning of the session---the "Hi, how are you doing?"  part of the session---but when you evaluation is "significant and separately identifiable."  This means taking more time than just 5 minutes to explain or discuss an issue.  The 25 modifier is used with new patients, periodic reevaluations, re-injury, counseling (see the article to the left), release from active care, discharge.  It is generally used when you perform a procedure on the patient during the same session as the evaluation.  If you perform a procedure (as in Adjustment) on the patient on the same visit that you performs an exam and does NOT use the 25 modifier, you will not receive reimbursement from the insurance company. chiropractic billing medical billing

21:  This code is used only with the Evaluation/Management (E/M) codes.  Modifier 21 signifies that the face to face provided is prolonged or otherwise greater than that usually required for the highest level of E/M service within a given category.  This modifier is used when increased time is needed for a particular level of E/M service, without having the necessary clinical requirements for a higher level of E/M or a separate prolonged service add-on code.
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51:  Modifier 51 implies multiple procedures, when one or more procedure is performed on the same day.  The 51 modifier is also used if the same procedure is performed on two separate parts of the body.  A good example is an extremity adjustment performed on each wrist.  You would bill 98943 for the first wrist and then 98943-51 for the second wrist.  Do not use this modifier with 97010-97799 as these are multiple procedures by definition. chiropractic billing medical billing

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22:  Use the 22 modifier when your service provided is "greater than" usually required. Some codes are segmented by time, and this modifier can be used if the time is greater than 1 unit but less than 2 full units.  If the time requirement is 15 minutes, usually the minimum requirement for reimbursement for each unit of that particular procedure is 8 minutes.  If the procedure takes 15 minutes plus 4 minutes, you can use this modifier to signify "more than" 1 unit, but “less than” two. chiropractic billing medical billing

52:  The opposing twin!  The "less than" modifier.  Use this one for REDUCED services.  Under some circumstances, a service or procedure may be partially reduced or eliminated at your discretion. As an example, it can be used when not all views are taken on a "complete" x-ray series, yet no other CPT code fits the explanation of service.  Another example is the physical therapy code 97110.  If physical therapy is performed for 19 minutes, bill 97110 for the first 15 minutes, then bill 97110-52 for the remaining 4 minutes.


59:  This modifier is used to distinguish that a particular service is distinctly separate from another.  This is used for codes 97110, 97124, or 97140 when billed in conjunction with a Chiropractic manipulative therapy.  The 59 modifier indicates that a procedure or service was distinct or independent from other services performed on the same day.  Note that for 97140 to be paid, it not only needs a 59 modifier, but also must be performed in a separate region than the CMT service.
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Here you will find a few facts concerning billing Report of Findings and Counseling.
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Report of Findings - informing the patient of his condition and treatment options - sometimes is performed on the same visit as the initial exam, and sometimes it is reserved for the next visit.

Counseling occurs after your patient's treatment plan has started and your patient has asked for clarification concerning their condition, symptoms or any other issues that can surface in the course of treatment. chiropractic billing medical billing

chiropractic billing medical billing

• You cannot counsel on the first visit in conjunction with the exam.

• The time you spend counseling your patient must take up over 50% of the total session length.  

• You must have discussed one or more of the following with your patient:

              1.  Diagnostic results, impressions, and/or recommended diagnostic studies (Report of Findings)
              2.  Prognosis
              3.  Risks and benefits of treatment options
                   Importance of compliance with chosen treatment options
              4.  Risk factor reduction
              5.  Patient and family education

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Time is the controlling factor in these codes, it is important that you document your time. 
Click Here to download a form that you can use as a guide for documenting your counseling sessions. ChiroCode Institute of Arizona provided this form. Use the same codes for Counseling that you use for Report of Findings, 99212-99214
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Report of Findings: You cannot bill Report of Findings on the same day as a new patient exam.  If you do your report on the same day that you examine your patient, then you only need select the proper New Patient Exam Code.  These are 99201-99204.  The higher number of the code, the more in depth the exam, covering all of the key components listed below.
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If on the second visit you want to bill Report of Findings, the proper codes are 99212-99214, and once again, the higher the number, more more in depth the report.  In addition, your session needs to include at least two of these three components:

• History
• Examination
• Clinical Decision Making. 
  

And of course, you need to document these two things.  documentation is essential.  As Medicare has stated, "If you didn't write it down, it didn't happen."
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THE GRATUITOUS DISCLAIMER
This article is not intended as a replacement for authorized chiropractic billing educational programs.  The author is a Medical Biller and speaks mostly from practical experience.  Certainly it is up to the reader to research the topics discussed with their individual insurance carriers.


ARE YOU LEAVING MONEY ON THE TABLE?
Most chiropractors add physiotherapy to their study courses while training for Chiropractic. Unfortunately, many chiropractors do not take advantage of their Physiology licenses and therefore leave money on the table as far as insurance billing is concerned!  Although some insurance plans will not cover Physical Therapy performed in the chiropractor’s office (such as Medicare), there are plenty that do.  If you find yourself too busy to perform therapy for your patient, hire a CA certified in Physiotherapy to handle the Physical Therapy part of their treatment.


More insurance money for you, but WHO ELSE BENEFITS?
Your patient benefits also from PT being performed in your office.  It will facilitate their healing process, and if they complete their at home exercises, your patients will be less likely to re-injure themselves.  So if you are not performing PT for and on your patients, you are doing yourself and them a disservice.  


Check your PT coverage
When you, your staff or your billing service verify Chiropractic Insurance benefits, be sure to specifically ask for Physical Therapy benefits.  Ask if Physical Therapy can be performed by a Chiropractor.  If so, then ask if there is a separate deducible.  Normally there is not, but you want to be sure.  If you are contracted with the insurance carrier, ask what PT codes are covered.  List the ones you are likely to perform in your office.  If you are not contracted with the insurance carrier and do not know what specific codes are covered, bill out the PT codes you perform and see if they are covered.


Some of the most commonly paid and widely used Physical Therapy codes    
97010: Hot/cold packs (of late, BCBS and UHC does not pay for this procedure, but some ins companies do).  Billed as one unit, not timed.

97012: Mechanical Traction.  One unit is 15 minutes.  many practitioners use mechanical traction to prepare the patient for their adjustment.  The code does not pay a lot, but it can be a great adjunct to any therapeutic procedure or chiropractic adjustment.  Depending upon location, you can bill from $15.00 to $30.00 for one unit.

97110: One-on-one. Exercises to develop strength and endurance, range of motion and flexibility, one or more areas.  Therapeutic exercise incorporates one parameter (strength, endurance, range of motion or flexibility) to one or more areas of the body.  Examples include treadmill (for endurance), isokenetic exercise (for range of motion), each unit is 15 minutes.  We have billed up to 4 units successfully. Depending upon your location, you can charge from $30.00 to $50.00 per unit. Basically, 97110 is any exercise your patient performs while he is in your office. These include and are not limited to assisted stretching, exercises on the ball, hip roll, seated roll, etc.

97112: One-on-one. Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, one or more areas.  This code is intended to identify neuromuscular re-education, designed to re-educate the muscle for some function it was previously able to do (not intended to identify massage to increase circulation, etc).  This will usually be in the form of some commonly performed task for that body part. 15 minute units.  (Examples: feldenkreis, bobath, bap’s boards, desensitization techniques...)  Sometimes you will be asked for specific and detailed notes proving medical necessity if you use this code, be sure it is medically necessary!

97140: One-on-one. Manual therapy techniques - myofacial release, mobilization/manipulation, manual lymphatic drainage, manual traction, trigger point - one or more regions, 15 minute units, charges can be from $30.00 to $50.00 per unit, and a good average is from 1 to 3 units.

97140 is used to describe therapy which increases active pain-free range of motion, increased extensibility of myofacial tissue and facilitates return to functional activities.  This code is reported in units of 15 minutes.  It would include neuromuscular therapy, positional release, stretching and nearly any therapeutic technique performed manually for the purposes mentioned above.  This therapy is to be performed on an area separate and apart from the area of main complaint in order to successfully bill to insurance.  Append the 59 modifier to this code.

97124: One-on-one Massage, including effleurage, petrissage and/or stroking, compression, percussion, one or more areas, each 15 minutes


If the therapist is performing therapeutic massage in order to increase circulation and promote tissue relaxation to the muscles, then use code 97124. If treatment is based on or consists of a basic relaxation massage, this is the code to use. If, however, your intention is to increase pain-free range of motion and facilitate a return to functional activities, use the code 97140.  And don’t forget the modifier!

97535: Activities of daily living - self-care, home management training - direct one-on-one contact with the provider, 15 minute units.  This can consist of giving the patient exercises that he/she can perform at home.  You can demonstrate the exercises and give them a print out with diagrams and directions on it.  Some insurance companies pay, some don’t. One small insurance company I know of allows 25.00 for 1 unit.  Depending upon location, a DC can bill from $30.00 to $50.00 per unit, and not normally over 1 unit. Perform this service and bill this code only once every 6 weeks or so.


A WORD ABOUT DOCUMENTATION
DCs are on the hot seat these days with insurance carriers because of their lack of proper documentation.  If you don’t write it down, you didn’t perform the therapy!  Record the type of exercises performed, and if the code is a timed unit, record the start and end times of your therapy. 




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The financial welfare of any Chiropractic business that bills insurance companies is directly related to the percentage of reimbursement the Doctor receives from his insurance claims.  The percentage of insurance reimbursement is directly related to billing out procedures that the insurance company covers.  Finally, billing out the procedures that the insurance company covers is directly related to proper and thorough insurance verification.

Whether you, as the Doctor, do your own verification or if you rely on your front desk or billing service to do your verification, be sure it is being done correctly!

Is the Playing Field Even?
Perhaps you have noticed that when you call the insurance company, the first thing you will hear is the gratuitous disclaimer.  The disclaimer states that no matter what takes place during your telephone conversation,  chances are if you were given incorrect information, you are out of luck.  The disclaimer may include the following statement:  “The insurance benefits quoted are based upon specific questions that YOU ask, and are not a guarantee of benefits.”  If you do not ask for details, they may not tell you the details, so you are starting out with the short end of the stick!  And since you are already at a disadvantage, get a firm grasp on that stick and cover all of your bases. 

To start with, you will need much more information than the internet website or telephone automatic system will tell you.  Call the insurance company when you want to find out what the patient's insurance benefits are.  When you call the carrier, bypass the automated systems as much as possible.   Ask the automated system for a "representative” or “customer service” until you actually find yourself talking to a real person.

Have an insurance verification form in front of you so you will remember the key questions that need to be asked.  I will provide an insurance verification form that you can use.  Here are the some key points:

The representative will give you their name.  Write it down, along with the date of your call.  If you are out of network with the insurance company, get the in-network and out-network benefits, just so you can compare the difference.  

Deductible Information Essential
Find out the deductible, then ask how much has been applied.  Then ask, specifically, if the deductible amounts are COMMON.  If you do not ask, they will not tell you! If deductibles are common, you can be fairly certain that the applied amounts are correct.  If the deductibles are NOT common, find out how much has been applied to the in-network plan and how much has been applied to the out of network plan.

What does Common mean?  Common deductible means that all monies applied to deductible are shared.  Any funds applied through an in network provider will be credited for the in and out of network providers.  Any funds applied through an out of network provider will be credited for the in and out of network providers.  Another term for this is Cross-Over Deductibles.

Second question:  Is there a 4th quarter carry over?  This is good to know towards the end of the year.  If your patient has a one thousand dollar deductible and it is October, any money applied to that one thousand will CARRY OVER to next year’s deductible.  This can save you and your patient some big bucks.  If you do not ask, they may not share this information with you.

Since we are discussing Chiropractic, you will ask about the Chiropractic maximum.  What is the limit?  It may be a number of visits, it may be a dollar amount.  If it is a dollar amount, then ask:  Is this limit based on what you ALLOW, or what you PAY?  Some plans consider the allowed amount the determining factor, and some will consider the paid amount as the determining factor.  There is a BIG difference between the two!

If you bill Physical Therapy—and if you don’t, then you should!—ask about the Physical Therapy benefits.  Can a Chiropractor perform Physical Therapy?  If the answer is yes, then ask:  Are the Chiropractic and Physical Therapy benefits combined, or are they separate?  Usually the plan will be similar to:  12 Chiropractic visits and 75 Physical Therapy visits are allowed.  If they are separate, then after your 12 Chiropractic visits, you can begin to bill Physical Therapy codes only.  If you add a Chiropractic adjustment on the claim after the 12 visits, that claim may be considered under the Chiropractic benefits and you will not receive payment.  If you bill Physical Therapy codes only, then the claim will be considered under the Physical Therapy benefits and you will receive payment.

We’re Not Done Yet!
However!  You need to be even more specific about this.  After being told that the Chiropractic and Physical Therapy benefits are indeed separate, and you have been told that a Chiropractor CAN bill Physical Therapy, then ask:  Is Physical Therapy billed by a DC considered under the Chiropractic or the Physical Therapy benefits?

At this point you can almost see your insurance representative roll their eyes at your incessant questioning.  Don’t worry about that, just get the information. Sometimes you have to ask the same question a few different ways to get a complete reply.

Many Chiropractic Assistants have regretted not asking this question.   Some plans will allow a Chiropractor to bill Physical Therapy, but if the doctor is a Chiropractor, then ANYTHING the doctor bills will be considered “Chiropractic Benefits.”  In that case, you will only be reimbursed for the maximum number of visits allowed to a Chiropractor, even if you CAN bill Physical Therapy also.

There are plans that will allow a Chiropractor to bill Physical Therapy codes after all of the Chiropractic benefits have been exhausted.  How will you know if you do not ask?

Here is another good question:  Is there a limit on how many units can be billed per day?  Many plans have not limit, but some plans will limit the procedures billed to 4 units per day.  Four UNITS, not modalities.  97110 is 1 modality, but if you bill 2 units of 97110, that counts as 2.

How many Office Visits (exams) are allowed per year?  This can help you decide how many re exams to perform and bill for during the year.

And of course, it is helpful to ask:  Have any of these Chiropractic and Physical Therapy (and Acupuncture) benefits been used this year?

Is pre authorization required?

The insurance representative will only give you partial information unless you specifically ask. 

Document your call!
When you are satisfied that you have all of the information that you need, ask the representative for a reference number.  If you have been given erroneous information, at least you can refer to the call when appealing the claim.

Click HERE to download an excellent sample Chiropractic Insurance Verification form.  It is in PDF and the form can be filled out with your PDF program. Or you can print it out.                                                   

If you have any questions or would like to communicate with me about anything in this article, just call Deb Tru at 602-525-9888 or Email DebTru@tmedbilling.com

Happy billing!

Tru Medical Billing.........at your service