Presenting Problem
Some payers are denying Mechanical Traction (CPT Code 97012) on the same date of service as the Chiropractic Manipulative Treatment (CMT 98940-98942).
Findings
Here is the rationale of one payer: “…both mechanical traction and spinal manipulation on the same date of service as the procedures, for all intents and purposes, are redundant. Manipulation and mechanical traction are designed to mobilize joints, increasing segmental motion and restoring appropriate spinal biomechanics. Inasmuch as the procedures are essentially duplicative, either spinal manipulation or mechanical traction would be appropriate on an office visit encounter, but not both on the same date of service.”
Assessment
They are not the same. Such a rationale (or denial tactic) implies that DCs should trade-in their adjusting tables for another intersegmental traction table.
From a CPT® coding perspective, 97012 is a physical medicine mechanical traction modality that does not require attendance. Various other modalities might also assist in accomplishing and/or complementing some of the same objectives as the CMT codes or 97012. However, that does not make them duplicative. Additionally, the CMT services are in a different section of the CPT code book and are unique manual techniques that require physician attendance. Furthermore, the descriptions of these codes from CPT do not match with such an assessment.
Remember that CMT is an “umbrella” term, meaning that there are many, many different techniques that are utilized by chiropractors that are billed with the CMT code. For example, an upper cervical practitioner might only adjust C1-C2, bill 98940 and utilize 97012 for rest of the body. The same can be said of the Activator method and many other techniques where the service has different objectives.
Further appeals rights exist within ERISA law (health plans sponsored by an employer in the private sector). From this perspective, the payer could be forced, upon denial, to produce all evidence, including research, as the basis for their denial.
Plan
- Refuse to accept the denial and make an appropriate appeal.
- Give them the rationale stated above.
- When such cases are ERISA type claims, and you have the patient’s authorization as their representative, demand documentation that supports their “adverse benefit determination.”
The Attractive Alternative
- Hire an outsourced chiropractic billing service that handles all of this for you. Your entire practice will have more bandwidth to focus on patients and patient acquisition. The best part is that you will end up making more money each month. See for yourself with our profit calculator or simply request a free consult to speak with an expert.