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Chiropractors treat a wide variety of conditions such as back pain, neck pain, herniated discs, sciatica, pinched nerves, and migraine as well as complex conditions. Many practices rely on Chiropractic Billing Services to report diagnosis and treatment accurately on claims. When it comes to billing and coding complex chiropractic conditions, proper documentation and using the right coding practices are essential to tell the whole story, communicate the findings, and prove medical necessity. Changes in the Evaluation and Management (E/M) rules and ICD-10 codes have made it easier for chiropractors to report complex conditions to insurers.

  • Office/Outpatient E/M Codes (new patient): In 2021, coding guidelines for outpatient E/M services were revised with the result that patient codes 99202-99205 do not require the 3 key components –patient history, clinical examination, and medical decision making (MDM) — or reference typical face-to-face time. Effective 2021, each of the services includes a “ medically appropriate history and examination,” and code selection is based on the level of MDM or total time spent on the date of the encounter. The provider can now document medically necessity to establish a diagnosis, evaluate the status of a condition, and recommend the appropriate treatment option.
  • ICD-10 codes to report complex conditions to the highest level of specificity: ICD-10 coding allow for specificity.
    • ICD-10 codes can indicate if the condition is on the right side or the left and if the condition is chronic or acute.
    • ICD-10’s seventh character is an extension that allows for documenting the phase of care for injuries and other conditions with external causes. The extension will indicate if the patient is in the active phase of care, the rehabilitation or healing phase, or is suffering from a sequela of the injury.
    • Providers can report all diagnosis codes that identify the patient’s condition to the highest degree of specificity.

By reporting the patient’s co-morbidities that impact their current diagnosis, chiropractors can demonstrate the necessity of the level of care provided for the complex condition.

    • Documentation: History, subjective complaints and objective findings should be clearly documented. This will allow the medical coder to assign specific diagnosis codes to describe the patient’s condition. For e.g., M54.2 Cervicalgia, M47 Spondylosis, and M54.5 Lumbago are non-specific ICD-10 codes commonly used in the chiropractic office. By documenting the reasons for the back or neck pain, more specific codes can be assigned to better report the patient’s health condition.

An article on offers the following guidance on documenting complex chiropractic conditions:

    • After conducting an examination, if it is decided that X-rays should be taken due to the presenting condition, the ordering and analysis of the X-rays would be considered in the complexity of the data to be reviewed and analyzed.
    • Ordering and prescription of proper custom orthotics would also be documented in the medical decision-making.
    • The nature of the mechanism of injury, the treatment options and the diagnoses are documented and if all these factors are rationally related in complexity, the care is considered to be medically necessary.
  • Order and placement of codes: When a chiropractor reports multiple diagnoses, the order of the codes will also impact claim adjudication, in addition to using the codes to their highest specificity. For instance, Medicare instructs that the precise level of the subluxation must be listed as the primary diagnosis. So, when required, segmental and somatic dysfunction (subluxation) codes (M99.1 – M99.05) should be always placed in the first position on the Medicare claim form. However, other commercial insurance and liability carriers may not require this. Sometimes, certain medical conditions are “complicated” by other disorders. In such situations, the order of the conditions present is crucial. The correct order in which they should be stated in the claim form is:
    • Neurologic conditions
    • Structural problems
    • Functional disorders
    • Complicating factors
  • Payer requirements: Changes and new requirements for Medicare and private insurance make chiropractic medical billing quite complex. In both cases, of course, chiropractors must provide evidence to support both standard and complex treatments. CMS guidelines state: “ The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for the treatments. The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s). There are five spinal regions addressed: cervical region (atlanto-occipital joint), thoracic region (costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region” (ref. CPT® Professional Edition 2017 p. 672). Further, Medicare guidelines state that a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation, and that the Modifier AT must not be used when maintenance therapy has been performed.

Private insurers also have specific guidelines for coverage of chiropractic services. For e.g., Aetna considers chiropractic services as medically necessary when all of the following criteria are met:

– The member has a neuromusculoskeletal disorder.

– The medical necessity for treatment is clearly documented.

– Improvement is documented within the initial 2 weeks of chiropractic care.

Partnering with an experienced chiropractic medical billing company is the best way for chiropractic practices to report complex conditions correctly and avoid claim denials and audits.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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