If you haven’t been personally afflicted by the latest round of shenanigans from Aetna in regards to bundling chiropractic adjustments and manual therapy (97140), be forewarned – Aetna’s abusive practice is spreading quickly. Over the last several weeks, I have been inundated with emails from perplexed chiropractors in all parts of the country who have suddenly noticed that their 97140 claims are being routinely denied by Aetna.
Unfortunately, in case you aren’t up to date on your history, Aetna’s bad habit of making these “errors” in claims processing has been tried before and they have been sued for this in the past as well. And, although we are certainly capable of making errors in the areas of chiropractic billing, coding and documentation, the blame in this case rests squarely on Aetna.
Coding Facts About Chiropractic Manipulative Therapy & Manual Therapy
Despite what is happening on EOBs and in our reimbursements (or lack thereof) delivered by Aetna, here are the facts:
- 97140 does NOT equal the chiropractic adjustment. According to CPT guidelines, 97140 describes “Manual therapy techniques.” Examples given are but is not limited to, mobilization/manipulation, manual lymphatic drainage and manual traction. Therefore, if a chiropractor were to perform manual traction, a specific example given by the CPT, then coding it as 97140 would be entirely appropriate.
- Chiropractic adjustments have their own set of CPT codes. According to the CPT, chiropractic manipulative therapy (i.e the chiropractic adjustment) is represented by codes 98940 to 98942. CMT performed on an extremity is coded as 98943.
- CCI Edits: According to CCI claim edits (CCI = Correct Coding Initiative), CMT codes (98940-42) cannot be performed in the same anatomical region as 97140 in order for both procedures to be reimbursable. This is called bundling.
- Use of Modifier -59. There is a correct way to bill for both 97140 and your CMT on the same visit. CCI edits dictate that 97140 is a “column two” procedure when combined with CMT, which means that the two are not mutually exclusive (that’s column one). Instead, when these two codes are performed and billed on the same day, they require a modifier (-59) to indicate that they are separate and distinct procedures. By using the modifier -59, you indicate to the payer that you understand the coding edits and that, in this circumstance, the procedures were distinct and performed in separate anatomical areas, Therefore, both of these procedures should be payable.
Requirements for 97140 and CMT to Be Paid on the Same Day
There are several billing, coding and documentation requirements that need to be in place in order for your manual therapy and chiropractic adjustment to be payable on the same day. Here they are:
In your notes:
- Your documentation must clearly show that your CMT was performed at a separate anatomical site from 97140. Example: you adjusted the lumbar spine and performed manual therapy on the trapezius muscles.
- Your documentation should indicate the time spent for your 97140 work, as this is a timed service.
On your claim form:
- Modifier 59 should appear in box 24D on the line you billed 97140.
- Diagnosis pointing must occur in box 24E to show that the manual therapy was performed in a separate region than the CMT
Aetna’s Recent Denials
- Despite your correct coding and application of the above principles, chiropractors are experiencing bundling denials from Aetna on 97140 – even with the modifier 59 present and your correct diagnosis coding efforts.
- The bundling denial appears to be largely the result of the claims editing tool in Aetna’s claims processing software.
- According what Aetna has been explaining to providers, “there are very few indications for the application of manual therapy techniques, as described in procedure 97140, in addition to manipulation.” [Apparently, Aetna knows nothing about how chiropractors practice, chooses not read the CPT or both.]
- In addition, most chiropractic billing specialists who have been inquiring about these denials have been informed that modifier 59 will not override this edit [despite the fact that this is precisely what the modifier is for!].
What can Chiropractors do to Fight the 97140 Denials?
1. Correct YOUR Errors: If your claim was rightfully denied because you failed to meet the conditions necessary to have 97140 and your CMT paid separately, then you need to fix that right away else you are giving away your care.
2. Appeal! Your first step should be to appeal each of these denials with your documentation. Appealing a payer’s decision is always an option for you unless you have specifically been told that no appeals are afforded to you for that claim.
3. Make Noise! Contact your state association. I know several state associations are already aware of this situation. Contact your national association. Contact your insurance commissioner. Let the patients know that Aetna is not interested in paying your claims properly.