It is with sadness that I report at the problems with CPT code 98943 (for a chiropractic extremity adjustment) have continued for well over 5 years now and it does not look like that the challenges will be disappearing anytime soon. Unfortunately, we routinely get emails from confused chiropractors and their staff regarding problems they are having while wrestling with payers over getting CPT code 98943 paid. The only silver lining in this dark cloud is that there are some chiropractors who CAN get 98943 paid without incident. Essentially, this post is for the rest of you who continue to have struggles with getting extremity adjustments reimbursed.
Before we dive into the solutions, let me provide you with a brief history to put these problems into context:
The Start of CPT Code 98943 Problems
In my opinion, the first challenge with 98943 stems from the fact that it is essentially a code used only by chiropractors. The CPT code sets itself it is owned by the American Medical Association and they are the ones that dictate new codes to be used, updates, revisions and deletions of CPT codes. So it’s pretty easy to see that a CPT code that is only going to be utilized by practitioners of one relatively small health profession is certainly not going to be at the top of anyone’s priority list if problems emerge.
Predictably, problems did emerge. The first problem that many chiropractor saw was that there 98943 extra spinal adjustment was bundled in with the other adjustment services they provided (98940, 98941 or 98942). Fortunately every coding book is pretty clear on the fact that these are separate and distinct codes, so sharp chiropractic assistants appeal the bundling errors and routinely win.
Unfortunately, the problems with CPT code 98943 didn’t simply stop with bundling errors. Weather in an attempt to circumvent the bundling issue or to satisfy some misguided payer request, some chiropractors begin adding the modifier– 51 to their 98943 coding in order to get paid. What was misunderstood (by both the chiropractors and/or the payers) is that the Modifier 51 is to be used for “Multiple Procedures” that are related, where the secondary procedure is less integral than the primary. At the least, this obviously does not apply to chiropractic adjustment coding and worse, it can actually cause problems as we addressed in a previous post on CPT code 98943. Most remarkably, this problem was even addressed by “the authorities” and published in the CPT Assistant December 2013 issue where it was simply stated that “Modifier -51 (Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940-98943).”
More Problems With CPT Code 98943 After the ICD-10 Shakeup
That event should have signaled the end of problems chiropractors had with CPT code 98943, but unfortunately the chaos continued up until 2015, when a new problem emerged. If you can recall your history of modifier modifications, you will remember that in 2015, Modifier 59 replacements were introduced. For no good reason, this seemed to re-ignite problems with 98943 as providers (or payers) started believing that the Modifier -59 or one its replacements (-XE, -XS, -XP or –XU) would look rather nice when accompanying an extremity adjustment. Worse, in the wake of the (still ongoing) transition away from modifier 59, this move only seems to add to the already abundant confusion regarding this modifier and its replacements.
Here are the simple facts about Modifier 59 (and its replacements) and the source of some confusion. According to the CPT, “Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.”
In chiropractic terms, it is neither “normal” nor “abnormal” to report 98943 along with a spinal adjustment. Some chiropractors routinely adjust extremities, some don’t. But since it is an adjustment to an extraspinal area, as opposed to the other chiropractic adjustment codes that apply to spinal manipulations, it’s my opinion that the modifier 59 should not be necessary based on the “not normally reported” together rationale.
From another angle, modifier 59 is also used to indicate separate and distinct services that do not overlap when the practitioner is performing timed codes. In other words, you can use the Modifier 59 (and its replacements) to communicate to a payer that yes I performed this code for X minutes and that code for Y minutes and you would like to be paid for both. By applying the modifier 59, this would signal the payer that you understand the coding requirements and that payment is applicable.
While that angle makes sense from a general coding perspective, it does not really apply to problems with CPT code 98943, because neither the extremity adjustments nor spinal adjustments (98940, 98941 or 98942) are timed. Therefore, it should be unnecessary to indicate with a modifier that you performed both; the different codes should do just fine.
Simple Strategies for CPT Code 98943
To make things really simple, there should be NO modifier necessary for the use of CPT code 98943. That’s it.
But, again, one of the biggest problems with CPT code 98943 is that it is exclusively used by chiropractors. Therefore, even though the solution and strategies should be simple, you can anticipate problems anyway because the payers are less familiar with the code due to its small volume compared to codes used by many different professions.
Solving CPT Code 98943 Problems Once & For All
So, if no modifier is needed, how do you get 98943 paid if one of the above problems occur?
If a payer refuses to pay because of bundling, you must appeal the claim and reference that these are separately payable codes from your chiropractic spinal adjustments. The only time this should fail is if the payer’s policy is to bundle these codes. In that case, the payer should provide you with a written reference to that policy. And if that’s done, there’s nothing you can do about it if you are contracted with that payer as your contract has essentially allowed you to agree to their coding misinterpretation.
Moving onward, if a payer attempts to bundle your payment insists on Modifier 51, use the above citation from the CPT Assistant to refute their nonsense.
And finally, if a payer insists that Modifier -59 (or one of its replacements) belongs attached to 98943, turn the tables back on them. Ask to see an explanation of their policy and the rationale WHY this modifier would be appropriate for 98943. You will gain two things here: either (1) the payer will give you their kooky reasoning and you will have it in writing that they will pay for your service provided you follow their bizarre rules; or (2) you will enlighten them to their own mistake and force them to reprocess your claims so that they will be paid correctly. Either way, you win — and you can solve your CPT code 98943 problems once and for all!