Chiropractic and Passive Modalities -Purpose, Medical Necessity, and Billing in a Chiropractic Setting
INSURANCE
Samuel Collins
Modalities can be an integral, effective, and necessary service as part of chiropractic treatment protocol. However, the goals and purposes of these modalities must be understood in order to assure proper utilization and reimbursement. Due to potential overutilization, there is heightened scrutiny of the use of passive modalities, particularly for multiple modalities done on the same visit. All services, including modalities, should be utilized with specific attention to the phase of care, its purpose, and from a reimbursement standpoint having stand-alone value. Therefore, a treatment plan should be developed with planned modalities (frequency and duration), measurable and attainable goals (short term and long term), and anticipated duration of care with a reasonable expectation that the identified goals will be met.
From the insurance reimbursement standpoint, there are specific guidelines that outline use and necessity. Following is the language from CIGNA Chiropractic Coverage Policy 0267 and their instructions relating to chiropractic use of modalities: “In addition to spinal manipulation, which is a manual therapy, other modalities, both passive and active, are often used as adjunct treatments. Passive modalities include treatments such as electrical stimulation, therapeutic ultrasound, high-voltage galvanic stimulation, therapeutic heat, cryotherapy, passive assistive exercise, traction, diathermy, and massage. Passive modalities aie most effective during the acute phase of treatment, as they ai e typically directed at reducing pain and swelling. They may also be used during the acute phase of an exacerbation of a chronic condition. The optimal duration of a course of passive modalities is a maximum of one to two months, after which their effectiveness diminishes, and patient dependency may develop.
Treatment plans for patients who are at risk for developing chronic conditions should de-emphasize passive care and refocus on active care approaches. When utilizing passive modalities after a lasting physiological benefit has been reached, the modalities serve only to facilitate the manipulation and aie considered integral to the manipulative procedure.”
Note the emphasis on effectiveness is in the acute phase. Therefore, if passive modalities are done beyond the acute time frame (likely no more than first four weeks), the incidence of denial is higher based on medical necessity. While the services beyond the acute phase may “feel good or relaxing” to the
This language is consistent in the industry among all carriers as evidenced here with the following Blue Cross Blue Shield position: “Phase One - Treatment provided is to alleviate pain and is directed to limit the extent of the injury or condition, reduce signs and symptoms of inflammation, and to minimize functional disability. The short-term use of adjunctive therapeutic modalities or procedures may be appropriate in addition to manipulative procedures.”
Clearly, the utilization of modalities may be appropriate and necessary and paid of a comprehensive chiropractic treatment plan. The codes for modalities are separated into two categories: supervised or unattended services with the CPT codes 97010 to 97028. These aie services that do not require direct one-onone patient contact. This means the provider may apply the modality but does not need to remain in contact. For example, a heat treatment (whether hot packs 97010, infrared 97026, or diathermy 97024) can be applied, and once it is set, the provider may leave the patient and simply check on the response periodically. For this reason, these services can only be billed for unit maximum regardless of the time spent or the number of regions of application.
he second category of modalities is considered constant attendance, meaning these services require direct one-on-one contact by the provider. These codes aie 97032 to 97036, and due to the constant attendance element, have a time value of 15 minutes. This allows these specific services to be billed in multiple units, based on the time of application. The minimum time required for one unit is not 15 minutes, though, and is based on the eightminute mle for timed services. The eight-minute rule follows this format: one unit requires eight to 22 minutes; two units 23 to 37 minutes; three units 38 to 52 minutes; and four units 53 to 67 minutes. Therefore, the billing requires a minimum time, and if it is less than eight minutes, the service is considered not billable or reimbursable. This time is also considered cumulative for all timed services. This means that if you spend 10 inmutes each, on two separate services, it would only qualify for one unit because 20 minutes was spent cumulatively. In this scenario, only one unit of service may be billed, though it may be the higher valued of the two services provided.
To avoid denials and requests for additional information on medical necessity, consider the common protocols from evidence-based treatment guides that state, “Most uncomplicated cases can be adequately managed with spinal manipulation plus one or two adjunct modalities. Using more than 2-3 adjunctive passive modalities in one visit, in addition to joint manipulation, is considered excessive and not of pro ven benefit.” The basic purpose of most modalities falls into three categories: reduce pain,
reduce spasm, and circulation (inflammation). Consequently, multiple modalities to the same body region would be hard to defend as separately medically necessary because the services will be deemed as duplicative. In addition, prolonged use of passive modalities absent of flare-up or exacerbation would also be seen as not being medically necessary. Treatment guides aie consistent in noting that long-term or prolonged use of passive modalities may or will cause patient dependence.
These passive services aie productive and can hasten the response to care, but they ai e adjunctive to the chiropractic manipulation. Therefore, it is reasonable in many instances to include passive care, and these services can and should be reimbursed in addition to the chiropractic manipulative services. They also do not require any special modifiers for coding reimbursement when billed with chiropractic manipulation.
Samuel Collins is a nationally recognized expert oi insurance billing and coding for chiropractic, acu puncture, and physical medicine billing. Sam is als a member of the Optum Health (United Health CareS Physical Health Reimbursement Committee for 10 vear~
and part of the Stakeholders Committee andpeer review for World Health Organization lCD]], Traditional Medicine Coding. Sam aided in the revision and expansion the original HJRoss Diagnostic Corollaries to the current Digital Chiropractic Diagnostic and Treatment Corollaries. For more information on programs and products of HJ Ross go to www.hjrosscompany.com
