# Chiropractic anyone?



## jaldrich (Oct 22, 2008)

I'm struggling with a provider who provides chiropractic adjustments in his office.  He's an MD, who happens to use the manipulations...I'm curious...would you code this with a CMT code AND an E/M, or just the CMT? 

S:   Here with neck and back pain. She was a passenger involved in an MVA October 9, 2008, restrained passenger. She is having some mid-back pain, a little low back discomfort as well as neck discomfort. No headache. No loss of consciousness. No visual changes. 



O: VITAL SIGNS: WT: 140. BP: 128/74. P: 72. A 16-year-old. 

MUSCULOSKELETAL:  She has some muscle and tenderness in the mid-thoracic spine as well as cervical spine and to a little lesser degree in the lumbar region. She has tenderness in the right sacroiliac joint, mid-thoracics as well as cervical spine at C2 and C3. Carinal nerves 2-12 grossly intact. 



A: Sprain/strain cervical and thoracic spine, lumbar spine. 



P: Manipulation employed without difficulty in cervical spine, thoracic region, L5, and sacrum without difficulty. Stretching exercises. At this point, I think this is going to resolve fairly quickly. I will have her come back in a couple of weeks for recheck and use ibuprofen p.r.n. 


Thanks in advance,
Jennifer


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## jennsomers (Oct 22, 2008)

hey, i used to bill for chiro. you can use e/m on the initial visit (consult with mod 25) but the ins co's dont like to see office visit with manipulation codes. or they may pay the e/m since it may be a lower fee schedule. let me know if you need anything else since i still help them out once in a while.


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## jesuspadilla (Oct 22, 2008)

Hi There. I worked for a chiro and pt provider before. I would try to use the e/m code for this with the 25 modifier as well, also along with CPT 98940- modifier 59 (adjustment or manip.) make sure that the adjustment (manipulation) cpt codes are correct for the amount of adjusting the provider did (1 area or multiple areas). Why this? Patients would come in for there first visit as a new patient. we would bill the e/m code (ofc. visit) along with the adjustment (manipulation) and modalities with the appropiate modifiers. when the same patient would come back months later, we would re-eval them with a e/m code (established patient) with 25 modifier. depending on what the patient requested, sometimes we would bill out for the adjustment (manipulation) only. Remember, to have your proper documentation for the 59 modifier. make sure that it is documented in the medical record. i hope this may lead you in the way... let me know what the outcome is...


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## takore (Oct 22, 2008)

Hi There,

Try it with E/M with Mod 25, 98941 -59 (CMT to 4 spinal regions) and 97110 (Stretching Exercises). 

Hope this helps.

Tina


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## okiesawyers (Oct 23, 2008)

CPT states to code also significant separately identifiable E&M service (99201-99499)  I would make sure your documentation supports a separately identifiable E&M.


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## LLovett (Oct 23, 2008)

Be careful using timed codes like 97110, based on this note you do not have time listed so this would not be a billable service. Also if Medicare patients are being treated I suggest you educate the provider on their guidelines because they are strict and extensive.

Good luck


Laura, CPC


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## mmiscoe (Oct 27, 2008)

*CMT plus E/M*

This question, like all others, depends on who you are billing.

Who is the carrier.  As this is an apparent personal injury (auto) claim, what code utilization standards are incorporated into the reimbursement component of the state auto statute?

Assuming general coding priniciples, I note that an MD performed the service.  Are you sure of that?  While not inappropriate for an MD to report CMT, or a DC to report OMT (the difference is in outcome not the licensure of the provider as the code title suggests), in my experience, I see MDs billing CMT where the practice is a multi-specialty practice (MDs and DCs and sometimes PTs who join together to form a multi-disciplinary group).  If this is the case as I suspect, the billing suggests that a DC actually performed the service and the MD is billing it under incident to rules.  You must evaluate if the state licensure rules, as well as the rules pertaining to the reimbursement scheme (looks like an auto case - so the state auto statute) permit incident-to billing.

With Respect to the E/M:  Assuming that this was an initial encounter, I would likely agree that the E/M service is beyond the usual pre, intra and post service analysis contained in the CMT service.  As such, reporting the -25 on the E/M service would be appropriate.  If this was an established patient encounter, then I would need to compare the prior notes to see what was substantively difference to justify the repeat analysis.

I score the E/M service as follows:  H=EPF, E=EPF (95) PF (97), and DM=Low.  If a new patient, 99202, if an established, 99213.

With Respect to the CMT: I note that the manipulation service was performed on regions of the spine that are not clearly related to the injury.  The subjective data suggests primarily neck complaints and some vague mid back/low back discomfort.  The diagnosis suggests sprain/strain of the neck, mid back and low back although the examination data does not confirm this.  At best it shows myofascitis that may or may not have been caused by the accident.  With CMT, especially where a DC is involved, it is common to stretch the areas involved to support the higher 98941 code.  This is a form of upcoding and before approving a 98941 in this case, I would like to see the patient intake data that contains the patient's actual complaint.  My guess is that it is limited to the cervical region.  Once that was evaluated, you would be able to make a definitive determination on the level of CMT.

Note:  The use of the -59 modifier on the CMT code is neither required nor proper as suggested by one commenter.

Finally, there is insufficient information to determine what "stretching exercises" means.  Were these recommended or performed?  Even if performed in the office, it looks like it will be a "couple of weeks" until the patient returns.  As such, there could be no expectation that the in-office exercises would yield a substantive functional improvement in the patient's condition and as such, they would not be medically necessary.

Also, I am concerned with the approach that some commenters suggest.  There seems to be a "try this" theme to some of the responses.  As coders, we are required to apply appropriate criteria to make a correct representation of the service so that the carrier can make a correct payment determination.  Accuracy is our goal. Consider that the correct representation of the service might cause the service to be correctly denied such that the payment burden shifts to the patient.

As I spend most of my time defending providers who have tried any number of seemingly good ideas to get paid - only to face substantial post payment refund demands or worse - civil/criminal false claims litigation, all should be extremely careful in suggesting or following such approaches. 

Research the applicable standards to the carrier you are billing.  Find out what code usage rules apply.  Only then can you determine the correct answer to your question.

I hope you find this useful.


Michael D. Miscoe JD, CPC, CHCC


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## zvankleek1 (Oct 28, 2008)

Was this a new patient visit or a follow-up?  If it were a new patient then I would be using 98926 and code your EM-with a 25 modifier.  You stated that your physician was an MD not a chiropractor correct, so the 98925-98929 would be more appropriate.


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## jaldrich (Oct 28, 2008)

She is an established patient, but this was the first visit for the back/neck pain from the MVA.  The doctor is not a DC, nor does he work with a DC.  He performs the manipulations, with his MD licensing.  He formerly was in a chiropractic business as the chiropractor. He then expanded (?) his licensing and is an MD only, not a DC.  He has seen this patient in the past for medical problems.


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## Billing500 (Sep 19, 2015)

*Can an MD bill OMT*

Sorry to reignite this thread, but I'm having trouble determining if an MD can bill OMT (98925, for example).  The physician is actually an Anesthesiologist MD, DC (dual licensure).  

Some articles I've read suggest that an MD can provide and bill for the service, while others limit OMT to DOs only.   Help!


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