Background information and BCBS claims processing protocol for chiropractors regarding code 97140.
If you’re a chiropractor or in-house biller who is frustrated with denied claims, you’re not alone. We stay abreast of coding trends across the country, and are always eager to share information regarding chiropractic billing and coding.
Tips to avoid Code 97140 Denials
Our billing experts have received lots of inquiries over the past year regarding denials from BlueCross BlueShield (BCBS) for certain services rendered and billed. We want to assist you in dealing specifically with code 97140 and the claims edit process. But first, here’s a little background on the subject.
BCBS Claims Processing Protocol
A claims processing protocol was instituted by BCBS in November 2017, (“code-auditing enhancement” via “clinically validating modifiers”) that began denying some providers’ claims on codes that require the modifiers 25 or 59 (including XE, XS, XP, XU).
BCBS has indicated that it is designed to identify medically unnecessary evaluation and management (E & M) services and manual therapy services (CPT® Code 97140) to curb the practice of some providers of performing and/or billing E & M services at every visit, as well as the practice of routinely providing 3-4 units of massage billed under 97140, when these services are not medically necessary.
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Claims Edit Process applicable to network providers:
The claims edit will look for “clinical validation” for modifiers 25 and 59 to validate the way modifier use is supported. This initial stage of clinical validation does not include medical records review.
Nurse claims analyst reviews the claim history for that patient. If, in the judgment of the analyst, the patient claims history warrants use of the edit, it will be applied to that claim and the service will be denied.
If the patient’s claim history shows a certain frequency of procedures for that patient, the edit will be applied and the claim denied, even if some of the procedures were performed by a physician other than the one submitting the current claim.
Every BCBS member-patient is treated differently, depending on claims history.
The provider who receives a denial under this claim edit may submit a Claim Inquiry/Request for Reconsideration or appeal, or both, and submit medical records for review.
A claims inquiry is not an appeal; it is a provider inquiry, and if the provider wants a claims inquiry, he or she should ask for a reconsideration
EOB denial language that informs the patient the claim is denied because the provider used incorrect coding or that the benefit is included in payment for another service, aka “bundled”. No where do they indicate that this requires review of history and reconsideration. BCBS acknowledged that the language could be questioned, so they will be making changes
In addition, providers still have the option of filing an appeal (in addition to a claim inquiry) within 180 days of the denial.
The actual difference between a claims inquiry and an appeal remains vague, other than the claim is routed to a different (more appropriately staffed) department and does not impact the ability to take all appeal steps on a claim.
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