EM Coding Alert

One call to your payer may be your ticket to bringing in chiropractic E/M payments.

Some payers, including Medicare, do not pay for your chiropractor’s E/M services for established patients. You may have better luck with payers paying you for E/M services for new patients. Chat with your payers to learn what you need to change to see reimbursements.

Read on to learn the criteria for receiving payments for your new patients and what CMS says about allowing chiropractors to bill for E/M services.

Be Prepared, E/M Services May Only Be Paid for New Patients

When you report a chiropractic service and an E/M service for the same beneficiary on the same date of service there’s no guarantee that Medicare and some other payers will pay for both. Most payers consider the E/M work part of the doctor of chiropractic (DC) service. 

The American Chiropractic Association (ACA) supports the payers’ opinion by stating, “… it is inappropriate to bill an established office/outpatient E/M code (99211-99215) on the same visit as chiropractic manipulative treatment (CMT) because CMT codes already include a brief pre-manipulation assessment.”

Good news: But you can use one of the four CMT procedure codes with new patient E/M codes, (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient, …) and get paid for the E/M separately. You’ll report one of the following CMT codes:

• 98940 (Chiropractic manipulative treatment [CMT]; spinal, 1-2 regions)
• 98941 (… ; spinal, 3-4 regions)
• 98942 (… ; spinal, 5 regions)
• 98943 (… ; extraspinal, 1 or more regions).

“For these services to be paid appropriately, the correct E/M codes need to be used,” says Doreen Boivin, CPC, CPB, CCA, owner of Chiro Practice, Inc. in Saco, Maine. 

When the patient is new, with new injuries, exacerbations, or periodic re-evaluations, some experts find that adding modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code you’re reporting allows you to see reimbursement for both the E/M service and the CMT service. Be sure the documentation supports reporting them separately before adding 25, however. 

Resource: Refer to www.acatoday.org to read more about ACA guidelines for coding E/M with CMT.

Ask Your Payer for E/M Coding Guidance

Some payers agree with paying the E/M separately for both established and new patients, but first they enforce criteria that you must meet. You need to learn your payers’ rules. 

Example: The Washington State Department of Labor & Industries (L&I), which administers Washington’s workers’ compensation program, says there is a limit of one payable chiropractic care visit per day. Washington L&I will pay E/M codes for new patients with the chiropractic care visit codes, but only when you meet the following criteria:

• The E/M service is for the initial visit
• The E/M goes beyond the usual pre- and post-chiropractic care work
• Attach modifier 25 to the E/M code
• Ensure documentation describes both the E/M and the chiropractic care.

Washington L&I does allow payment of established patients DC care visits if an established patient needs re-evaluating for an existing issue. 

Even if you think you have met your payer’s criteria, you may have issues getting the reimbursement you deserve. “It seems that the insurance industry prefers manipulation codes after the first visit,” says Arthur Berman, DC, owner of Berman Chiropractic, Pittsburgh, Pa. ”[I] never use an E/M code unless I am either investigating a new event or performing procedures that do not include an adjustment. Every time I used an E/M code and a manipulation code on the same visit, I got it rejected even with modifiers applied.”

Stay tuned: After receiving very few comments in 2014 on the topic of allowing chiropractors to bill separately for E/M services, CMS said, “Any possible changes to our current policy on allowing chiropractors to bill E/M services will be addressed in future notice and comment rulemaking.”