Manual therapy is an effective option that is widely used by physical therapists, massage therapists, chiropractors, and osteopaths to treat pain and musculoskeletal disorders. As therapists work to rehabilitate patients, they can rely on experienced providers of physical therapy and chiropractic billing services to file accurate claims. Having a clear understanding of how to bill private insurance and Medicare is essential to receive payment for manual therapy services.
Defining Manual Therapy Techniques
Manual therapy techniques are used to treat the restricted motion of soft tissues in the extremities, neck, and trunk. They include a wide range of hands-on and physical treatments such as massage and manipulation of muscles, and techniques to mobilize joints and promote functional recovery.
The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) Description of Advanced Specialty Practice (DASP) (2018) defines orthopaedic manual physical therapy (OMPT) as: “An advanced speciality area of physical therapy practice that is based on manual examination and treatment techniques integrated with exercise, patient education, and other physical therapy modalities to address pain, loss of function, and wellness”.
Manual therapy is widely used in the management of upper extremity musculoskeletal disorders. Techniques Include
- Trigger Point Therapy
- Active Release Techniques
- Assisted Active Range of Motion (AAROM)
- Passive Range of Motion
- Lymph Drainage
- Stretches (muscle, neural tissue, joints, fascia)
- Instrument Assisted Soft Tissue Mobilization
- Joint Manipulation
- Joint Mobilization
Billing Medicare for Manual Therapies
Medicare covers multiple manual therapy techniques with proper documentation. Manual therapy is reported using CPT code 97140.
CPT code 97140 – Manual Therapy Techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, every 15 minutes. It also includes myofascial release/soft tissue mobilization.
Descriptors of manual therapy:
- Manual therapy is used in an active and/or passive fashion to help effect changes in the soft tissues, articular structures, and neural or vascular systems.
- The intent of the service is to increase pain-free range of motion and facilitate a return to functional activities.
- An example is the facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened connective tissue.
- Manual therapy is used when a loss of motor ability impedes function.
CPT codes 98940-98943 – Chiropractic Manipulative Treatment (CMT)
CMT is a form of manual treatment to influence joint and neurophysiological function and can be provided using different techniques. Here are the conditions for Medicare coverage for CMT (as listed by United Healthcare Medicare Advantage):
- Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation of the spine to correct a subluxation (that is, by use of the hands)
- The patient must require treatment by means of manual manipulation of the spine to correct subluxation and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectations of recovery or improvement of function.
- Manual devices may be used by chiropractors for manual manipulation of the spine, but Medicare does not recognize an extra charge for the device itself.
- No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered.
The following CPT codes are covered by Medicare
98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions
98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions
Medicare does not reimburse code 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions
When submitting the claim:
- Use modifier AT – Acute treatment when reporting service 98940, 98941, and 98942
- Include the following information –
- The primary diagnosis of subluxation
- The initial visit or the date of exacerbation of the existing condition
- The CPT code (98940, 98941, 98942) that best describes the service
- The appropriate modifier that describes the services
Note: The National Correct Coding Initiative (NCCI) edits created by the Centers for Medicare and Medicaid Services (CMS) require that the manual therapy techniques be performed in a separate anatomic site than the chiropractic adjustments in order to be reimbursed separately. Both codes could be billed if all conditions are met:
- Documentation should support medical necessity for the use of both CPT codes
- For the timed manual therapy CPT code, the service has to be performed for a minimum of 8 minutes to bill one unit.
- Modifier 59 should be appended to 97140 to indicate that it is a distinct procedure and is performed at a different anatomic region than the chiropractic adjustment that day.
Commercial Insurance Coverage for Manual Therapy
Private insurers have specific coverage rules and documentation requirements for different types of manual therapies. Let’s take a look at Optum’s policy on manual therapy.
Optum’s definition of Manual Therapy is adapted from the American Academy of Orthopedic Manual Physical Therapy (AAOMPT) and American Physical Therapy Association (APTA): A clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation/mobilization, used by the clinician to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.
Conditions for coverage of soft-tissue and joint manual therapy techniques:
- Broadly, manual therapy is indicated when there is mechanically induced musculoskeletal pain ie, pain that is provoked and relieved by specific motions or positions
- Criteria that are important for the correct application of manual therapy include: specificity of the procedure; direction and amount of force; the duration, type, and irritability of symptoms; and patient and clinician position
- CPT codes covered: 97140, 98940, 98941, 98942 and 98943
Optum states that code 97140 (Manual therapy techniques) may be billed on the same date of service as a CMT code when the manual therapy service is provided to a different, noncontiguous body region than the CMT.
An article in chiro.eco notes that Optum clarifies contiguous and non-contiguous body regions and notes that treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. [NCCI, 2017]. For instance, the policy notes that the treatment of myofascial structures using manual therapy techniques in the same organ (spine), where CMT was performed and was contiguous (cervical and thoracic), does not constitute treatment of different anatomic sites.
The treatment of myofascial structures using manual therapy techniques in the same organ (spine), where CMT was performed and was not contiguous (cervical and lumbar), does constitute treatment of different anatomic sites.
Optum requires documentation of the following criteria to support the clinical necessity of manual therapy services:
- The clinical indication and appropriateness of the selected manual therapy technique, including the need for skilled care services for treating a musculoskeletal condition
- The clinical rationale for a separate and identifiable service must be documented when both CPT code 97140 and a CMT procedural code are reported on the same date
- Description of the manual therapy technique e.g., joint manipulation, myofascial release, mobilization, etc.
- Location e.g., spinal region(s), shoulder, thigh, etc.
- Time (applicable only to CPT code 97140, which includes a timed-therapy services requirement)
Manual therapy is often used in a multimodal approach that focuses on the recovery of the patient’s functional capabilities. All therapy services are generally covered based on the duration and intensity appropriate to the severity of the impairment and the patient’s response to treatment. The patient’s needs, course of therapy and response to therapy must be documented for each date of service. Billing manual therapy is challenging as payer rules and guidelines differ. Support from experienced chiropractic and physical therapy medical billing service provider can go a long way in overcoming these challenges.