Cracking the Code

Staying up to date helps DCs overcome coding confusion.

By Caitlin Lukacs

Coding for insurance reimbursement can be a confusing process. With new codes created and old codes revised on a yearly basis, it’s easy to miss the changes. Staying up to date on coding changes is the best way to take the uncertainty out of the process, say coding authorities. 

As Craig Little, DC, DABCO, a member of the ACA’s Coding Manual Subcommittee and Coding Reimbursement Committee, explains, “Coding is a language. It’s a way for us to communicate ‘I’m treating a human being, and this is what I’m doing.’” Codes tell insurance companies exactly what procedures and treatments a doctor used, as well as the value of these services.

Dr. Little believes that coding has become a baffling process for some doctors of chiropractic because they don’t stay knowledgeable about the changes and additions that take place each year. “Our language sometimes changes,” he says. “Whether this change is because of new technology, alterations in procedures or adjustments in the value of a treatment, practitioners need to refer back to the [ACA’s Chiropractic Coding Solutions Manual] from time to time to discover how to report what they’re doing. They need to understand that [coding] is an on going process.”

The Process
New codes are created when there are new procedures or new modalities used by doctors and specialists. Older codes may also be refined or revised based on new information about the procedure. Dr. Little says that, in terms of creating codes, new technology is the driver more than anything else, and there are hundreds of Current Procedural Terminology® (CPT®) codes proposed each year.

The process of writing a new code starts with medical specialty societies. After a specialty society develops a new procedure or treatment, it must create a proposal for a code to describe that particular service. The proposal is then discussed, evaluated and eventually accepted (or rejected) by the multidisciplinary American Medical Association CPT panel. The panel reviews the medical literature regarding the procedure and defines it by way of a vignette, which is essentially a five-digit number plus a narrative description—which includes what the doctor does, how long it takes, and whether there are physical stresses associated with the procedure.

The vignette is evaluated by the Relative-value Scale Update Committee (RUC). The RUC is a multidisciplinary group that measures the actual value of the service by surveying the societies and specialists who do the work. They measure every aspect of the procedure, including the amount of time it takes to complete the treatment, the level of stress it places on the doctor, the practice expenses involved and the amount of malpractice liability necessary to cover such a service. With this information, the RUC determines a value, which it then recommends to the Centers for Medicare and Medicaid Services (CMS).

The entire process is extremely expensive and time consuming. The development of a single code can cost hundreds of thousands of dollars in research and take years to complete.
 
Not only are new codes continuously developed, but the older codes are regularly analyzed and reevaluated. The AMA’s CPT Manual is reviewed every year by a new group of doctors and experts, and the RUC not only makes annual recommendations about the values of the codes, but also performs a broad review of those values every five years. The ACA’s Chiropractic Coding Solutions Manual is reviewed and revised annually, as well.

2009 Updates
This year, there is only one new procedural code that chiropractors need to be aware of: 95992, for Canalith repositioning procedures such as the Epley maneuver. The code describes the procedure for treatment of benign paroxysmal positional vertigo (BPPV). This new code was developed by ACA in conjunction with the American Academy of Neurology, the American Physical Therapy Association and the American Academy of Otolaryngology-Head and Neck Surgery. It marks the first time that ACA has been involved in such a collaborative effort.

Anthony Hamm, DC, DABCO, DABFP, a member of ACA’s Coding Manual Subcommittee and Coding Reimbursement Committee, says although the procedure has been around for some time and has been described by another code, the old code wasn’t a very good description of the service, necessitating the development of a new code.

In addition to this new procedural code, several new diagnostic codes that may pertain to chiropractic care were accepted in 2008. Codes 99441-99444 are categorized as “Non-Face-to-Face Physician Services” and deal with consultations over the phone or through e-mail. Code 99441 is used when a physician speaks with an established patient, parent or guardian over the phone about an issue that did not stem from an office visit within the past seven days and does not result in an office visit within the following 24 hours. This code is used when the telephone discussion lasts between five and 10 minutes. Codes 99442 and 99443 are for the same situation as 99441, but they are used when the length of the telephone discussion is 11 to 20 minutes or 21 to 30 minutes, respectively. Last, code 99444 describes a situation where a physician uses electronic communications, such as e-mail, to discuss an issue with an established patient, guardian or healthcare professional that is not related to a service provided by the physician within the past seven days.

Be sure to read about these new codes in the ACA’s 2009 Chiropractic Coding Solutions Manual, as there are restrictions on when they can be reported and with what other codes they can be paired.
 
Staying Up to Date
It’s important for doctors to stay up to date on coding changes for several reasons. Coding mistakes can become a clinical issue, a liability issue and a financial issue. Doctors must code properly, both procedurally and diagnostically, to avoid audits and to ensure that they receive the compensation they deserve for their services.

One of the easiest ways to stay current is to purchase the ACA’s Chiropractic Coding Solutions Manual each year. Michael Massey, DC, CCSP, a member of ACA’s Coding Manual Subcommittee and chairman of the Coding Reimbursement Committee, says there are enough changes in each edition to warrant purchasing the new ones as they come out. “It’s not just about changes in coding; there are also changes in how you approach coding,” Dr. Massey explains. “We’re always working toward making [the manual] better and easier to use. We add new sections because we know what questions have been asked in the past year. For example, we might add a section about quality measures because we received a bunch of questions about it and saw that it would be useful to include in the manual.”

In addition, ACA offers several resources to help doctors of chiropractic better understand and improve their coding. ACA members can log onto the Coding Resource Center, available at www.acatoday.org/coding, which provides AMA CPT descriptions, ACA coding clarifications, template appeal letters and FAQs. There is also a place on the site where members can submit insurance questions, which will be answered by coding experts. 
 
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Correct Common Coding Errors

• Billing for multiple time-based codes, such as several units of manual therapy (97140) when a CMT was the only service performed, is inappropriate. You cannot replace a CMT code with another code if CMT was the actual service performed.

• In cases where a limited number of manipulations are allowed, DCs are sometimes advised by coding consultants to use an E/M code instead of a CMT code to get around the limit on CMT.  This is inappropriate. You are required to bill the code that best describes the service rendered.

• CPT code 97039, unlisted modality, should be reported for hydro-bed, dry hydro-bed, aqua-bed, etc.  Despite suggestions by some manufacturers and/or suppliers of these devices, it is inappropriate to report this service as 97022, whirlpool. The work involved in whirlpool includes assisting the patient in and out of the pool, and cleaning and disinfecting the equipment.

CPT is a registered trademark of the American Medical Association.

For coding questions, email insinfo@acatoday.org.