Contextual Coding

Sanna, Mark

There are more than 7,500 CPT(TM) codes; however, doctors of chiropractic use only 25 to 30 of these codes most of the time. DCs may use any code Listed in the AMA CPP(TM) Manual as long as it describes the service performed, is within the scope of practice in the doctor of chiropractic’s state, and is clinically indicated. This article will review 4 of the most commonly misused CPT(TM) codes: 97110, Therapeutic Exerdses; 97530, Therapeutic Activities; 97112, Neuromuscular Re-education; and 97150, Therapeutic Procedures Two or More Individuals.

Therapeutic Procedures

Active care is included in the AMA CPP(TM) Manual under the heading Therapeutic Procedures. According to CPT(TM), Therapeutic Procedures are applied one-on-one by a therapist or physician to improve function. They include stretching, using wobble boards or balance boards, lifting weights, riding a bicycle, using a treadmill, resistance exercising, etc. In other words, this type of care involves the active participation of the patient. The goal of active care is to improve the effectiveness of chiropractic adjustments. As chiropractic moves away from a pain-based model of care into the paradigm of functional restoration, patients appreciate how active care enables them to participate in the healing process.

Consistent Coding

By definition, the context in which events occur provides meaning to those events. The word context is derived from the Latin word contextere, which means to weave together. When applied to coding for active care, a mastery of contextual coding is necessary, as 1 code may “fit” more than 1 service based on its context. Correct coding requires knowledge of the published definitions, as well as the selection of the code that is consistent with the context woven out of the patient’s presentation, physical examination findings, diagnosis, the plan of care you prescribe, and the goals set for the treatment you deliver. In terms of correctly coding for the active care procedures you perform, consistency is the key; all of the pieces of the puzzle must fit together. And they all must be documented in the patient’s record.

Time-based Codes

All of the Therapeutic Procedure-active care-codes require direct one-on-one patient contact by the provider of the service. Time-based codes allow reimbursement based on the amount of time spent with a patient in performing the service. In a chiropractic practice, a full 15-minute increment must be spent with the patient to bill the code. Subsequent units may be billed for each additional 15 minutes spent. When a procedure or service isn’t completed to its fullest extent, you should report it as a reduced service. This is done by appending a 52 modifier, “reduced service,” to the time-based procedure code when you perform less than one 15-minute unit. For example, 97110-52 represents a session of Therapeutic Exercise that did not last 15 minutes. When billing insurance carriers for reduced services, do not discount your fee. Bill the fee for the full service, and the carrier will make the reduction.

Coding for Active Care

Without the knowledge provided by contextual coding, an observer could view a patient performing a Therapeutic Procedure-for example, exercising with a Gymnic ball-through a soundproof window looking into your rehab exercise suite, and would not be able to determine the proper code to assign to the procedure. In fact, based on the context of the exercise, the session could be coded 97110, Therapeutic Exercises, or 97530, Therapeutic Activities, or 97112, Neuromuscular Re-education, or even 97150, Therapeutic Procedures Two or More Individuals! An overview of how context can affect code choice should help clarify any confusion.

The code 97110, Therapeutic Exercises, should be used to code for exercises used to develop a single exercise parameter. These parameters include strength, endurance, range of motion, and flexibility. Examples of Therapeutic Exercises include using a treadmill for endurance, isokinetic exercise for range of motion, lumbar stabilization exercises for flexibility, and Gymnic ball for stretching or strengthening. Armed with this information, our observer viewing the patient performing Gymnic ball exercises would need to examine the patient’s record to determine that the exercise was prescribed with a goal to increase 1 particular exercise parameter. Our observer would also have to note if the provider was working one-on-one with the patient, and that a full 15-minute session was performed, prior to assigning the code 97110.

97530, Therapeutic Activities, should be assigned when multiple exercise parameters are involved, including balance, strength, and range of motion. Therapeutic Activities must also be related to a functional activity with direct functional improvement expected. Our observer would have to examine the patient record for a goal to improve a specific functional activity and the multiple exercise parameters the provider seeks to improve, as well as note that one-on-one contact for 15 minutes was documented. With this contextual information, the Gymnic ball exercise could be coded 97530.

Neuromuscular Re-education, 97112, should be used when describing those exercise activities that affect proprioception. It is also used to describe the re-education of balance, coordination, kinesthetic sense, and posture. Once again, our observer would have to go to the patient record to determine that the outcome of improved proprioception was documented for the 15-minute, one-on-one Gymnic ball session.

If our observer were to note that the provider was working with more than 1 patient performing Gymnic ball exercises at the same time, the proper code to assign the session would be 97150, Therapeutic Procedures Two or More Individuals. When supervising more than 1 individual performing a service that requires direct supervision, the code 97150 is used for each patient. For example, if Neuromuscular Re-education is performed in a group setting, use code 97150 and not the individual code 97112.

Clinical Documentation Is Key

Clinical documentation is the key to contextual coding. Using the correct code alone is not always sufficient. Careful clinical documentation is required and may be requested by the payer. Lack of clinical documentation is the No.1 reason for denial of service by payers. Most insurers live by the claim-handling rule, If it wasn’t written down, it wasn’t done. Properly documented care will assist you in selecting the correct code. It will also help eliminate unfair reimbursement practices toward the chiropractic profession. For additional information, an excellent resource for correct coding written specifically for doctors of chiropractic is the ACA’s 2004 Chiropractic Coding Solutions Manual.

Dr. Mark Sanna is the CEO of Breakthrough Coaching, which offers a 1-day coding seminar, “Navigate the Insurance and Coding Process, ” in partnership with the ACA. This CEU-approved program is designed to provide the most up-to-date coding information by the most knowledgeable coding experts. Contact Janet Ridgley, 800-986-4636, or e-mail Jridgely@amerchiro.org.

Copyright American Chiropractic Association Oct 2004

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