According to recent reports, chiropractic practices received denials from Blue Cross and Blue Shield (BCBS) for claims billed with modifiers. Medical billing outsourcing companies that provide chiropractic billing services found that most of the claims denied were those that required the 25 and 59 modifiers. The Explanation of Benefits (EOBs) indicated that the modifiers were used inappropriately or utilization of the modifier was higher than average. In December 2017, the Illinois Chiropractic Society (ICS) reported that in the cases they reviewed, the procedure code and modifiers were billed correctly based on the claims information, but that the denials are the result of a new code-editing feature that BCBS announced to all provider types.

The ICS strongly urged chiropractors to:

  • Appeal the specific denial by demonstrating a valid use of the modifier
  • Appeal the denial by pointing to the specific documentation that clearly demonstrates medical necessity

This experience has put the spotlight on the use of modifiers for chiropractic coding and billing. Chiropractic modifiers are reported along with CPT codes to tell the insurance company that there is something unique about the services being billed. Correct use of modifiers can increase reimbursement. On the other hand, if codes that require a modifier are billed without one, the carrier will reject the claim with an explanation on the EOB of bundling with another service. The key to using modifiers to ensure maximum reimbursement is to understand each payer’s specific recommendations on the matter.

Appropriate Use of Modifiers 25 and 59 in Chiropractic Medical Billing

The American Medical Association describes chiropractic manipulative treatment (CMT) (98940-98943) as a form of manual treatment to influence joint and neurophysiological function. The five spinal regions referred to for CMT are: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joints); lumbar region; sacral region; and pelvic (sacro-iliac joint) region.The five extraspinal regions are: head (including temporomandibular joint, excluding altanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen.

The CMT CPT codes are:

98940: spinal, 1-2 regions
98941: spinal, 3-4 regions
98942: spinal, 5 regions
98943: extraspinal, 1 or more regions

Let’s take a look at the use of modifiers 25 and 59 when reporting chiropractic services.

Modifier 25

The general guidelines on reporting modifier 25 with CMT codes are as follows:

  • CMT codes include a pre-manipulation patient evaluation.
  • Additional evaluation and management (E/M) services may be reported separately using modifier 25, if the patient’s condition requires a separate E/M service, above and beyond the usual pre-service and post-service. So if manipulation and E/M codes are billed for the same visit, it is necessary to attach modifier 25 modifier to the E/M code.
  • Providers should check commercial and federal payer guidelines when using modifier 25
  • As the E/M service may be caused or prompted by the same symptoms or condition for which the CMT service was provided, different diagnoses are not required for the reporting of the CMT and E/M service on the same date.

The bottom line: modifier 25 should be used only when DCs perform an assessment above and beyond the adjustment.

Modifier 59

The National Correct Coding Initiative (NCCI) edit program developed by the Centers for Medicare and Medicaid Services (CMS) is used by carriers and third party administrators in an effort to prevent improper payment when certain codes are submitted together. Modifier 59 and some other modifiers are exceptions to the NCCI PTP (procedure-to-procedure) edits.

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

CMS instructs that documentation should support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. Modifier 59 allows the claim to pass Medicare bundling edits, which would lead to additional reimbursement for the physician.

Chiropractic manipulative treatment codes — 98940, 98941, and 98942 — comprise three procedures, that is, pre-assessment (history), manipulation, and post-assessment, bundled together. These procedures are cannot be routinely unbundled. If a distinct procedure is performed that is not inherent in the manipulation, a modifier should be appended to communicate to the carrier that an exception exists.

In January 2015, CMS released new subsets of the 59 modifier, that is, modifiers XE, XS, XP, and XU that may be used in lieu of modifier 59. When providing services such as neuromuscular re-education (97112), massage therapy (97124), manual therapy or trigger-point therapy (97140), and billing Medicare, doctors of chiropractic (DCs) should use the 59 modifier only as a “last resort”. Instead, using the XE, XS, XP, or XU subset modifiers would be more appropriate.

Modifier XE: Separate encounter—the service is distinct because it occurred during a separate encounter.
Modifier XS: Separate structure—the service is distinct because it was performed on a separate organ or structure.
Modifier XP: Separate practitioner—the service is distinct because it was performed by a different practitioner.
Modifier XU: Unusual non-overlapping service—the service is distinct because it does not overlap usual components of the main service.

In a 2017 article, CMS provides the following example of modifier 59 usage for CPT codes 97140/97530:

97140 – Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

97530 – Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

CMS states that modifier 59 may be reported if the two procedures are performed in distinctly different 15minute time blocks. For e.g., one service may be performed during the initial 15minutes of therapy and the other service performed during the second 15 minutes of therapy. The therapy time blocks may also be split. For e.g., manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy.

CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.

The bottom line:

  • Modifier 59 and other NCCI-associated modifiers should be only be used when appropriate and not to bypass a NCCI edit.
  • Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.
  • Before using NCCI-associated modifiers, DCs should check with their local Medicare carrier for guidance.

Outsourcing chiropractic medical billing and coding is a practical option to ensure that chiropractic services billed to Medicare and other payers are medically necessary, correctly coded and adequately documented. Coders and billing specialists in experienced medical billing outsourcing companies work alongside DCs to understand that specific ways chiropractic services are reimbursed, promoting accurate claim submission, reduced risk of scrutiny and denials, and optimal reimbursement.