Chiropractic Coding & Compliance Alert

Question: To measure “functional improvement” as a yardstick for efficacy of treatment, I often end up doing multiple tests and detailed evaluations. Is there a way to bill for this extra time and testing I am doing?

North Carolina Subscriber

Answer: It is wise on your part to stress documentation of measurable functional improvement, as many payers perceive “functional change” as a parameter for proving medical necessity for treatment. For example, the chiropractic policy of Cigna defines medical necessity as “demonstrated progress toward significant functional gains and/or improved activity tolerances.”

Medicare also believes that a chronic patient is one in whom further treatment may not resolve the patient’s condition. However, with continued therapy, there may be some functional improvement.

For functional evaluation of current deficits and needs, you may consider the physical medicine and rehabilitation code 97750 (Physical performance test or measurement [e.g., musculoskeletal, functional capacity], with written report, each 15 minutes).

However, here are certain things you would need to keep in mind:

• The billing guidelines say you may use the code preferably once a month. However, generally, providers perform the test thrice during the treatment period; once in the beginning, to establish a baseline of assessment data, then, during middle of the treatment to find out the improvement, and lastly before discharge, to evaluate the post treatment status.

• Remember to link a valid ICD-9 code (such as 711.x to 729.x) to 97750 in box 24 of the 1500 form. Ensure that the diagnosis does not include sprains, strains, ligament tears, or fractures. However, these may be a part of the diagnoses. If you fail to link the above said code to prove medical necessity for the claim, the system may reject it straightaway. 

• This service is distinct and does not bundle into the E/M codes 99201 to 99215, the physical medicine codes, or the chiropractic manipulative therapy codes.

• Spare the code from range of motion or muscle testing, and a computerized gait evaluation, as these tests are not considered to entail a detailed analysis of the patient status.

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