The October 2009 edition of the CPT Assistant featured some clarification on chiropractic coding issues specific to coding for Chiropractic Manipulative Treatment, both Spinal (98940-98942) and Extraspinal (98943).  In addition to spelling out what constitutes each of the five spinal regions, the CPT Assistant provided some additional clarification on the Extraspinal Regions that was previously left unclear in previous editions of the CPT code book.  Specifically, I would call your attention to the definitions of Lower Extremities and Upper Extremities, which are now well defined.

To give you a little background, the CPT (Current Procedural Terminology) coding book is published each year by the American Medical Association and is the “official” coding standard rules and guidelines for proper coding procedures throughout all health professions.  As the full volume of the publication is quite large, various spin-offs of the CPT book exist (such as ChiroCode) in specialty professions to help practitioners in specific disciplines access the portion(s) of the CPT that are relevant to their profession.  Similarly, the CPT Assistant is published each year for coding professionals (from all disciplines) and it clarifies updates, problems, commonly misunderstood items, deletions and additions to the  CPT codes.

For most issues of this pricey publication, the CPT Assistant has little relevance to anything we do as chiropractors mainly because we represent only a tiny fraction of health professions at large.  To be honest, each year, I wrestle with the idea of canceling my subscription but the occasional nugget of useful information I can pass on to you and/or my clients keeps me going.  The most recent issue of the CPT Assistant has by far the most relevant hairsplitting that has been published on chiropractic in a looooong time.  The issue featured definitions of chiropractic manipulative therapy codes (most of which you already know) but there were a few tidbits that were included that could potentially have a major impact on your ability to bill, code and document your services correctly.  Done right, they can help you INCREASE income.  If done incorrectly, you could be LOSING money.  Here they are:

Extremity Coding Clarifications
For Lower Extremities, perhaps the most critical definition for chiropractors is the inclusion of the “Hip” in this category.  As you know, a patient presenting with a hip problem could really have a chief complaint of SI joint pain, pelvic pain or problems in many other anatomical structures located in the surrounding regions of the lumbar spine, hip, pelvis or sacrum.

Similarly, many chiropractors have expressed confusion over what structures constitute the Upper Extremities.  The present edition of CPT Assistant also clarifies this issue: the upper extremities include the shoulder, arm, elbow, wrist, and hand.  Therefore adjustments that you perform in the Thoracic region of the spine would not include the shoulder, even though some of the surrounding structures are adjacent anatomically.  The CPT Assistant makes it clear: Shoulder Manipulations are Extra-spinal (98943).

From a coding, documentation or billing perspective, it is essential to be specific in your reporting of pain in these areas, as it may have significant impact on your selection of the appropriate CPT code to bill for your services and in turn, the revenues generated from that service.  For example, since the SI joint is classified under Pelvis for coding purposes, adjustments to this region would count towards the number of spinal areas for which you are billing.  On the other hand, if you perform an adjustment to the hip, your service should be coded as an Extraspinal Adjustment (98943) and would not count towards the number of regions you would choose for spinal area adjustments (98940-98942).

Potential Risks and Benefits of This Coding Clarification Obviously, if you incorrectly document, bill or code for any of these regions incorrectly, you run the risk of either upcoding your services (because you have billed for more regions than you truly adjusted) or downcoding your services (because you failed to bill for all the areas you adjusted).  Neither is correct and both have financial implications.

One final note: the CPT definitions of anatomical regions are not consistent with the diagnosis code selections included in the ICD-9 code set.  This discrepancy was pointed out in the 2009 edition of the ChiroCode Deskbook, but its application becomes particularly relevant when dealing with coding issues in reference to the regions mentioned above.  Because it may not be possible to correlate all anatomical regions with specific ICD-9 codes, use extra caution to make sure that your documentation fully supports both your choice of CPT codes and ICD-9 codes.  Failure to do so may result in your claim being denied or delayed.

Now that you have been informed,  the next step is to go back and correct your procedures if you have been doing it wrong.  For those of you who suddenly found out that you are leaving lots of money on the table by the current way you are billing, coding or documenting your services, let me suggest a three step plan:

1. Fix It! The insight is not the solution — your improvement requires action! So get to it before you expose yourself to potential audit trouble and/or keep losing hard earned money.
2. Admit That You Don’t Know Everything. This is sort of a “healthy” view of ignorance.  Some call it the beginning of wisdom.  It is the realization that you cannot possibly know everything there is about all aspect of your business.  Certainly there are other similar items that you don’t know that are also costing you money (or will cost you money if you are audited).  Once you can own up to that, perhaps it’s time to fill out my Practice Analysis Questionnaire and see how I may be able to assist you.  My review of your Questionnaire is free and there is no obligation to utilize my services, so the only thing you have to lose is your stubbornness to admitting you know everything.  By the way, just in case you think I may be a little hypocritical here, I don’t claim to know everything either.  It’s highly likely I know more than you about billing, coding, documentation as this is what I specialize in, but you won’t find me telling you how to adjust your patients or what to do with your 401K plan.  For some things, it is helpful to have access to someone with specialized knowledge around. If you can accept that line of thinking, fill out my Practice Analysis Questionnaire and we’ll talk.
3. Give Something Back.  There is potential for some of you to make big bucks off this blog post due to the fact that you have been doing it wrong for who knows how long.  Take an average of only 20 adjustments per week @ $50 per adjustment for 50 weeks of the year.  That’s a $50,000 impact on your practice for one item!  At the very least, you may owe me a nice dinner (just kidding), should hire me (kidding – sort of — it will cost you less than $50K and make you more) or give something back to the profession (not kidding at all — choose your state and/or national association and send a check – they need the money!).