Participating Chiropractor Manual

Transcription

1 Participating Chiropractor Manual Revised January 2005 Blue Cross and Blue Shield of Alabama, 450 Riverchase Parkway East, Birmingham, Alabama An Independent Licensee of the Blue Cross and Blue Shield Association Participating Chiropractor Manual - 1- January 2005

2 TABLE OF CONTENTS PREFACE... 3 PROVIDER ELIGIBILITY... 4 PROVIDER DATA MAINTENANCE... 4 IMPORTANT ADDRESSES... 8 IDENTIFICATION CARDS BLUECARD PROGRAM COMPLETION OF THE BLUE CROSS AND BLUE SHIELD OF ALABAMA CLAIM FORM 12 TIME LIMITS FOR FILING CLAIMS PROCEDURE CODES DIAGNOSIS CODES PLACE OF SERVICE CODES REMITTANCE NOTICE ELECTRONIC FUNDS TRANSFER OVERPAYMENTS AND THE VOLUNTARY CHECK RETURN TRANSMITTAL PROVIDER PAYMENTS TO BLUE CROSS AND BLUE SHIELD OF ALABAMA CHIROPRACTIC AND PHYSICAL MEDICINE INFORMATION DEFINITION OF CHIROPRACTIC CARE GENERAL PROGRAM GUIDELINES PHYSICAL MEDICINE GUIDELINES OFFICE VISIT CODING NEW PATIENT VS. ESTABLISHED PATIENT STANDARDS OF DOCUMENTATION PRECERTIFICATION MAINTENANCE CARE CRITERIA FOR BENEFIT COVERAGE APPEALS OF DETERMINATION NOT TO CERTIFY ADDITIONAL VISITS FIRST APPEAL SECOND APPEAL NON-COVERED SERVICES PARTICIPATING CHIROPRACTOR AUDITS CATEGORIES EVALUATED HEALTH MANAGEMENT Participating Chiropractor Manual - 2- January 2005

3 Preface Welcome to the Participating Chiropractic Network of Blue Cross and Blue Shield of Alabama. This manual was created to be a resource for both administrative and medical policies for your patients whose employer elected the Participating Chiropractic Benefit Program as part of their group coverage. We suggest using this manual online in order to take advantage of the links provided. CPT codes, descriptions, and other data only are copyright 2004 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. Disclaimer The following disclaimer is applicable to all telephone inquiries and automated communications systems (i.e., InfoSolutions, PhoneFax) to Blue Cross and Blue Shield of Alabama: The information provided is only general benefit information and is not a guarantee of payment. Benefits are always subject to the terms and limitations of the plan and no employee of Blue Cross and Blue Shield of Alabama has authority to enlarge or expand the terms of the plan. The availability of benefits is always conditioned upon the patient s coverage and the existence of a contract for plan benefits as of the date of service. A loss of coverage, as well as contract termination, can occur automatically under certain circumstances. There will be no benefits available if such circumstances occur. Participating Chiropractor Manual - 3- January 2005

4 Provider Eligibility The Participating Chiropractic Network is open to new Chiropractors becoming established in our coverage area. For Chiropractors who are already established but are not members of this network, membership is based on a demonstrated need for additional network providers in a geographical area. The first step to becoming a Network Provider is to obtain a provider number. You may request an application by calling our Provider Enrollment Department at or The last page of this application contains a question about the applicant s interest in becoming a member of a Preferred Provider Network. You must answer yes to this question to continue the process of being credentialed into the network. A no answer will result in a provider number being assigned, but no further steps being taken in regards to the network. During the credentialing process, the provider s history is reviewed to ensure that only the highest quality providers are allowed into the Participating Network. Some of the items reviewed include professional requirements such as licensures and/or restrictions, performance records such as audit results, practice patterns and legal history. Once credentialing is completed and the provider is approved, the applicant s provider number is identified as a member of the network and a Participating Chiropractor Agreement is mailed out. Provider Data Maintenance The Provider Data Maintenance area can assist you with inquiries regarding new provider numbers, changes of address, etc. You may fax your requests to or call for help with your Provider Data questions. Accurate and complete information is important for both Providers and Blue Cross and Blue Shield of Alabama. Blue Cross and Blue Shield of Alabama's provider file is utilized for remittance payments, Internal Revenue reporting, and publication mailings. To make any changes, complete the Provider Change Notification on the following page, sign, and mail or fax to the address below. This form is also available on our web site by visiting, selecting I am a Provider then selecting Forms under Provider Resources. Blue Cross and Blue Shield of Alabama Attention: Provider Data Maintenance Post Office Box Birmingham, Alabama Fax Number: Click here to view the Provider Change Notification Form. Participating Chiropractor Manual - 4- January 2005

5 Provider Resources Several options are available to you when you need to contact Blue Cross and Blue Shield of Alabama or need assistance with claims issues. Here is a brief overview of some of those resources. Electronic Practice Management Electronic Practice Management (e-pm) is the preferred method of communicating with us. Whether you chose to purchase a computer vendor product, or to use the Internet at no charge, this method can save you time and money. Both vendor products and the Internet allow you to: Submit electronic claims Pull audit trails. Audit trails tell you what claims were accepted or rejected (if rejected, gives the reason and allows you to correct and resubmit) Check the status of a specific claim Check patient eligibility and benefits (confirm that a patient is on a contract, whether or not the contract has preferred chiropractic benefits, confirm how much of the deductible has been met for this patient, etc.) Pull electronic remittances Obtain a payment history for the provider number (find out how much your payment was or will be on a given date) Look up a current Preferred Chiropractor Fee Schedule Additionally, when using the Internet version of e-pm, you have access to refund billing invoices, which are the letters sent to notify you of overpaid claims. To obtain more information about e-pm, both through vendor products and our Internet site, refer to. Click on I am a Provider, then under Provider Resources, select Provider Publications. Click Accept on the Physician s Current Procedural Terminology (CPT) disclaimer, and then review the EDI Times publication. If you need additional information, us at askedi@bcbsal.org, or call EDI Services at Toll Free Customer Service Access For providers who use the resources above, a toll free customer service number has been established to help with any information not available electronically. To be eligible for the toll free number, you must be able to access the above information electronically, and you must sign an additional agreement. To get a copy of the agreement, go to, select I am a Provider then under Provider Resources, select Forms. Under the Electronic Data Interchange heading, you will find the Customer Service Toll Free Agreement. Simply click on the link, print the form, and mail or fax to the appropriate place. To view the form, your computer must have Adobe Acrobat Viewer. If you do not have that, a link is provided for you to download it at no cost. Telephone and Fax Numbers For providers with no electronic access, PhoneFax is the next level of communication. PhoneFax is Blue Cross and Blue Shield of Alabama's computerized telephone information service for Preferred Care providers. PhoneFax is designed to quickly give you a patient's eligibility and copayment, a provider's last remittance total, chiropractic coverage, laboratory and x-ray riders, Managed Care benefits, and preadmission certification (PAC) coverage. The information given is based upon the latest information made available to us by our groups and their members. Participating Chiropractor Manual - 5- January 2005

6 Following are our PhoneFax numbers: With a touch-tone telephone you can call PhoneFax for the following information: Online detailed information on assigned claims; Amount applied to the deductible; Amount paid on a claim; Adjusted payment information; Line item information; Claim denial information; and Claim pending information. Information is available through PhoneFax on all patients covered by Blue Cross and Blue Shield of Alabama. For patients with an alpha prefix as part of their contract number, substitute the number of the corresponding letter on your telephone. For example, SNT = 768, MRR = 677, PRI = 774, BLS = 257, and INT = 468. Patient records that are maintained by another Blue Cross Plan will not be available through PhoneFax. For information on these contracts, call the telephone number on the back of the patient's identification card, or refer to the BlueCard PPO section of this manual. PhoneFax provides ongoing instructions to help you with your selections. Follow the instructions to obtain the information you need. When you become familiar with the instructions, you can move quickly through the script. You do not have to listen to all the menu items before you enter your selection. You may key ahead to receive information faster. Have the following information before you call: Your Provider Identification Number (PIN) Patient's contract number (for claim status) Date of service (for claim status) Entering Your Provider Identification Number The Automated Response Unit (ARU) will ask for your 3-digit plan code. If you practice in Alabama, your plan code is either 510 or 515. Press that number, and the pound sign. You will then be asked if you are receiving information for a Clinic Identification (ID). Clinic ID s are additional numbers used by practices with large number of providers to better control remittances. If you have a Clinic ID, you can find it on your remittance. Few, if any, chiropractic offices use a Clinic ID. It usually is a letter, followed by three numbers, such as C111. The system will then ask for your provider number, which you should key into the phone. Provider Inquiry Department If you are unable to get assistance electronically or through PhoneFax, there are Provider Telephone Representatives available at to answer your questions. These representatives help in three ways: (1) assist in claims filing instructions; (2) answer claims filing, eligibility and coverage questions; and (3) investigate and review claims that have been processed to ensure proper benefits have been provided. Participating Chiropractor Manual - 6- January 2005

7 Network Services Representative Your Network Services Representative serves as a liaison between the provider community and Blue Cross and Blue Shield of Alabama. These representatives educate providers through onsite meetings, town meetings, clarification of medical policies and claims filing issues. They are involved in developing provider networks and contracting. To find the Network Services Representative for your area, go to, select I am a Provider, then under the heading Provider Help, select Contacts by Location or Vendor, then click on Find Network Services Contacts. InfoSolutions -Medical Records InfoSolutions -Medical Records is an electronic health care information network that allows providers to access more complete and timely medical information on all their patients. InfoSolutions enables office management systems to retrieve provider and claims information electronically from Blue Cross and Blue Shield of Alabama, facilitating the care and treatment of patients by solving the common problems of information exchange. InfoSolutions has many features to help your practice become a leader in the delivery of efficient and cost effective medicine. Following is a description of these features: Patient information is available to initiate effective preventative care procedures. Time spent looking for or ordering medical records is eliminated. Confidentiality of a patient s medical record is enhanced within InfoSolutions through extensive levels of security with access provided only to authorized personnel. For more information on InfoSolutions, go to our web site,, and click on the InfoSolutions link on the left hand side of the page. Participating Chiropractor Manual - 7- January 2005

8 Important Addresses CLAIMS FILING BellSouth Refunds and Adjustments NASCO Refund Checks BellSouth Dedicated Service Center Blue Cross and Blue Shield of Alabama Post Office Box Post Office Box Birmingham, Alabama Birmingham, Alabama BellSouth Services Refunds and Adjustments BellSouth Dedicated Service Center Blue Cross and Blue Shield of Alabama Blue Cross and Blue Shield of Alabama 450 Riverchase Parkway East Post Office Box Birmingham, Alabama Birmingham, Alabama Blue Shield Claims Work-Related Inuries Blue Cross and Blue Shield of Alabama Blue Cross and Blue Shield of Alabama Post Office Box 2294 Attention: WRI Department Birmingham, Alabama Post Office Box Birmingham, Alabama Correspondence Blue Cross and Blue Shield of Alabama Post Office Box 2294 Birmingham, Alabama ICD-9 Coding Manual and HCFA Common Procedure Coding System (HCPCS) (Including Tapes) Federal Employees Medicode, Inc. Federal Employee Program (FEP) Med-Index Division Blue Cross and Blue Shield of Alabama 5225 Wiley Post Way Suite 500 Post Office Box Salt Lake City, Utah Birmingham, Alabama FEP Refunds and Adjustments FEP Dedicated Claims Post Office Box Birmingham, Alabama Medical Records Department Participating Chiropractor Manual - 8- January 2005

9 Provider News and Updates Blue Cross and Blue Shield of Alabama communicates with providers through many publications created solely for providers, including this manual. All of these communication pieces are available through our web site,. Here are some instructions on how to locate these publications and how to utilize the search engine: 1. Key on your address line. 2. Choose I am a Provider. 3. Under Provider resources, choose Provider Publications. You can either go directly to the publication that you need or choose Search located at the beginning of each list. If you choose Search: 1. Type in your topic (alpha and/or numeric). 2. Choose to search all publications or choose to search only one. You should receive a list of publication issues that contain your topic. Click on the issue that you are interested in. For the large publications, you may want to use the Edit, Find function provided by your browser. It is imperative that you take the time to read through the publications for information that may pertain to your practice. Many times you will receive only one notification of important changes. Some of the publications available are: ProviderFacts - This quarterly magazine contains information pertaining to Blue Cross and Blue Shield of Alabama's regular business such as claims filing, coverage, and network news. Special Bulletins - These bulletins are done on an as needed basis and pertain to Blue Cross regular business issues. EDI Times - This bi-monthly magazine contains updates and news related to electronic claims, remittances, audit trails, InfoSolutions, etc. With the placement of publications on, our goal is to provide accurate and pertinent information as soon as possible for the provider community. We believe the Internet and our notification system are the best tools to make that happen. To discontinue paper copies of newsletters, send an to prov@bcbsal.org. Include your address and provider number for notifications of newly added information. Participating Chiropractor Manual - 9- January 2005

10 Identification Cards The patient's Blue Cross and Blue Shield of Alabama identification card contains information you need for claims filing. Be sure to list the patient's contract number exactly as it appears on the card, including any alphabetic prefixes. Many Blue Cross subscribers will have an XAA prefix with their contract number. Illustrated below are sample identification cards: XAA Below is an illustrated card for a group that has a unique identification card: Participating Chiropractor Manual January 2005

11 BlueCard Program Many employers who are located close to state lines or who have employees in multiple states purchase an additional insurance product called BlueCard PPO. These patients are identified by the PPO in a Suitcase logo shown on the card below, or simply by the Suitcase logo on their card. The BlueCard Program was developed to improve administrative services and timely processing of claims for providers in all Blue Cross and Blue Shield Plan areas. It allows you to handle claims filing and processing with your local Blue Shield Plan, even though your patient is enrolled with another plan. Here is how it works: 1. A PPO member from another Blue Plan arrives at your office and presents an identification (ID) card with the PPO in a Suitcase logo. Always ask for the patient s ID card because coverage may change. 2. With the member s card in hand, call BlueCard Eligibility at BLUE (2583) to verify eligibility and coverage with the member s Blue Plan. 3. An operator will ask you for the member s alpha prefix (three characters found at the beginning of the member s ID card). Some ID cards may not have an alpha prefix. This indicates the patient does not have this benefit. Look for instruction or a phone number on the member s ID card for how to file these claims. 4. Remind patients that they are responsible for obtaining precertification/prior authorization from their Blue Plan, when necessary. 5. Once the patient receives care, file the claim with Blue Cross and Blue Shield of Alabama. These claims can be filed electronically. The local plan will manage claims collection, problem resolution and claims payment for you. Be sure to include the alpha prefix on the claim as it appears on the ID card. 6. The local plan pays you in the same manner you normally are reimbursed on your weekly remittance, while the member s Blue Plan send an Explanation of Benefits report to the member. 7. For any questions during this process, you should continue to contact Blue Cross and Blue Shield of Alabama, your local plan. Following is an example of a BlueCard PPO identification card: Participating Chiropractor Manual January 2005

12 Completion of the Blue Cross and Blue Shield of Alabama Claim Form On the following page is a copy of the CL-4 claim form. Certain items that need clarification are indicated below: 1a. List the identification number as shown on the patient's identification card. 5. Be sure to list the complete address, including zip code. Include the telephone number. 9 a, b, c, d Please complete if the patient is covered by another insurance policy. 10. Check the "Yes" or "No" block when applicable. 17 If you are billing for a service as a result of a referral, indicate the name and unique provider identification number (UPIN) of the referring provider. 21. List each ICD-9 diagnosis code for which services were rendered. 24A. Enter month, day and year (including century) for each service rendered. If like services are rendered over consecutive dates of service, enter the beginning and ending dates of treatment in the appropriate "From" and "To" spaces. 24B. Insert a two-digit place of service code to indicate where the provider treated the patient. 24D. Use the applicable five-digit CPT or HCPCS procedure code to describe the service rendered. Any modifiers applicable should be noted here. 24G. Please indicate the number of services rendered, as this may affect claims payment. 27. Payment for an assigned claim is made directly to the provider. Payment for a nonassigned claim goes to the patient and the provider can receive only limited information on the status of the claim. 31. The provider must sign and date the claim (actual or stamped) or the claim must be signed by an authorized representative as prearranged with Blue Cross and Blue Shield of Alabama. 32. Complete when laboratory services are performed outside the provider s office or services are rendered in an institution. If laboratory services are performed outside the provider's office, list the name of the laboratory and the laboratory's provider number. 33. You may order preprinted claim forms with this information. The PIN is the provider number. Example ABC Participating Chiropractor Manual January 2005

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14 Time Limits for Filing Claims All groups have time limitations for submission of claims. For most groups, claims must be filed within 24 months of the date of service. This information is available electronically as well, when verifying a patient s eligibility and benefits. Refer to the section of this manual under Provider Resources for more information. Some exceptions are (but not limited to): State of Alabama (group number 13000) and Public Education Employees Health Insurance Plan (PEEHIP) (group number 14000) claims must be received within one year of the date of service. The Federal Employee Program (FEP) (group number 53533) claims must be received by December 31 of the following calendar year of the date of service (e.g., a claim for January 12, 2003, must be filed by December 31, 2004). BellSouth claims must be received within one year of the date of service. NOTE You have 60 days to request a reconsideration of a BellSouth claim. There are other exceptions. If you are not sure of a time limit, you may call the appropriate Provider Inquiry area. Procedure Codes Procedure coding is a uniform method of accurately describing the type of service rendered. The complete procedure coding structure consists of both Physicians' Current Procedural Terminology (CPT-4) codes and HCFA Common Procedure Coding System (HCPCS) codes. CPT-4 is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by providers. The CPT-4 is published by the American Medical Association and is updated yearly. The address for ordering new CPT-4 books is listed in the "Important Address" section of this manual. Participating Chiropractor Manual January 2005

15 Diagnosis Codes An International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) code must be used to identify each patient's diagnosis or nature of illness or injury. A written diagnosis is not required when the code is given. Diagnosis codes are very important in making benefit determinations. They are used to evaluate whether or not services are medically necessary, if a condition is pre-existing, if Worker s Compensation is applicable, and for screening medical emergencies. Use the most specific 3, 4, or 5-digit code for that diagnosis. Many offices are putting zeros to the right of a three-digit code to make it five digits. This can make the code invalid or change the intended meaning. Include five digits if the ICD-9-CM codebook indicates that the use of the extra digits is required to more specifically describe the diagnosis. The series of diagnosis codes are for identifying current injuries due to an accident. If you are not providing a service for a current injury(i.e., injury that has occurred and required treatment within 90 days), then the diagnosis code should be selected from another section in the ICD-9-CM codebook. Participating Chiropractor Manual January 2005

16 Place of Service Codes 03 School 04 Hom eless Shelter 05 Indian Health Service Free-Standing Facility 06 Indian Health Service Provider-Based Facility 07 Tribal 638 Free-Standing Facility 08 Tribal 638 Provider-Based Facility 11 Office 12 Hom e 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Em ergency Room-Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Am bulance-land 42 Ambulance-Air or Water 49 Independent Clinic 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility-Partial hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse treatment Facility 56 Psychiatric Residential Treatment Center 57 Non-residential Substance Abuse Treatment Facility 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End-Stage Renal Disease Treatment Facility 71 Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Place of Service Participating Chiropractor Manual January 2005

17 Remittance Notice Blue Cross and Blue Shield of Alabama remittance checks are mailed each Thursday and will include claims processed in the previous week (Monday through Friday). A remittance statement will accompany each check identifying the claims processed. Should a claim be rejected, it will be indicated on the remittance statement by a Claims Adjustment Reason Code. In May 2002, Blue Cross and Blue Shield of Alabama redesigned paper remittances in order to comply with the Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set Standards. For details on the design and content, as well as definitions of the Claims Adjustment Reason Codes, and a sample of the remittance formats, please refer to Special Bulletin BS , dated April If you are unable to locate this bulletin in your office, you can find it on our web site. Go to, click on Healthcare Providers, Provider Services, and Provider News. Under the Medical heading, click on Special Bulletins, scroll down the left hand side until you see RSB , and click on that link to view the bulletin. Electronic Funds Transfer Electronic Funds Transfer (EFT), commonly called Direct Deposit, is available to any provider who meets the following requirements: Provider must maintain at least 85 percent electronic claims submission. Provider must receive Audit Trails electronically. Provider must receive Remittance Advice electronically and discontinue mailings of paper remittances. Provider must receive all Blue Cross and Blue Shield of Alabama publications via the Internet and discontinue paper. The authorization form required to begin EFT can be found on our web site. Go to, click on I am a Provider then under Provider Resources, selecting Forms. Under the Electronic Data interchange (EDI) heading, click on the link to the Electronic Funds Transfer Authorization Agreement to view and print this form. Participating Chiropractor Manual January 2005

18 Overpayments and the Voluntary Check Return Transmittal When a provider finds an overpayment on his/her remittance, the provider should deposit the check whether it is a complete or partial overpayment. The form on the next page, the Voluntary Check Return Transmittal, should be used to notify Blue Cross and Blue Shield of Alabama of the overpayment. Complete the form and attach a check in the amount of the overpayment only or choose Deduct and the amount will be deducted from a future remittance. The Voluntary Check Return Transmittal will save time for providers and Blue Cross by reducing the need for reissued checks. Another important benefit of utilizing the Voluntary Check Return Transmittal is that it will ensure that the provider's Information Return Form 1099 for medical payments is correct. The provider's check serves as support for deduction or reduction of revenues. Blue Cross and Blue Shield of Alabama created this form with the help of providers and the American Medical Association, Blue Cross and Blue Shield of Alabama to improve the process of correcting overpayments. Below is an explanation of how and when to use the form: Use the form to accompany any unrequested overpayments. Use one form per subscriber. More than one claim for a subscriber may be included on a form. Several forms may be combined on one check. You may copy the form on the following page, or obtain the form from our web site. Go to, click on I am a Provider then under Provider Resources, select Forms. Click on the link to the Voluntary Check Return Transmittal to view to form and print. This process can now also be handled electronically. From our web site, enter the Provider Access section by using your provider identification and password. Under the Payment Information header, click on Refund Billing Invoices, click on To Have Other Refunds Auto-Deducted, and follow the instructions. Provider Payments to Blue Cross and Blue Shield of Alabama Whenever making a check payable to Blue Cross and Blue Shield of Alabama, attach a copy of the invoice or the request for payment to your check. In cases of refunds of overpayments applicable to a specific claim, identify on the face of your check the name of the patient, the contract number and the date of service. By taking these actions you can assure that proper credit will be applied and avoid confusing situations where Blue Cross and Blue Shield of Alabama is unable to determine which account to properly credit. Click here to view the Voluntary Refund Check Transmittal Form. Participating Chiropractor Manual January 2005

19 Chiropractic and Physical Medicine Information Definition of Chiropractic Care Chiropractic is the branch of the healing arts concerned with human health and disease processes. Doctors of Chiropractic locate and remove, without the use of drugs or surgery, any interference with the transmission and expression of nerve energy in the human body. This is accomplished by means taught in schools or colleges of chiropractic that are recognized by the state board of chiropractic examiners. These providers consider man as an integrated being, but give special attention to spinal mechanics, musculoskeletal, neurological, vascular, nutritional and environmental relationships. General Program Guidelines This section of the manual outlines the medical policies and guidelines for coverage of chiropractic services by Blue Cross and Blue Shield of Alabama. The guidelines contained within this manual are not intended in any way to imply that treatment rendered over and above these limits constitutes over utilization or that if treatment is provided within these guidelines payment will be made. All claims for treatments are subject to review for appropriateness of treatment, medical necessity and contract limitations by a qualified reviewer. All treatment must include proper documentation for services rendered. Medical necessity must be documented for all services rendered. All charts will be reviewed for inclusion of a history and physical, plan of care, physical examination findings and progress or treatment notes. Payment is made in accordance with the Benefit Agreement applicable to the patient. The patient must be covered by a Benefit Agreement providing chiropractic care at the time services were rendered. Participating Chiropractor Manual January 2005

20 Physical Medicine Guidelines CPT Codes and For physical medicine services to be considered for coverage as reasonable and necessary, the following conditions must be met. The service must be performed by a chiropractor. The therapy must be of a skilled nature and require the services of a skilled provider as defined above. The services/therapy must not be maintenance in nature. Services performed must achieve a specific diagnosis-related goal. There must always be a documented expectation that the patient will, in fact, achieve reasonable improvement over a predictable period of time for the services to be eligible for reimbursement. Supplies furnished to patients who are receiving physical medicine services are not billable since they do not constitute services that require a skilled provider. Application of Surface Transcutaneous Neurostimulator (TENS) (CPT Code 64550) This procedure should be billed only once per course of treatment for the evaluation and placement of electrodes and should not be billed for on-going treatment. Mechanical Traction (CPT Code 97012) Mechanical traction is defined as the application of a mechanical force to the body in a way that separates, or attempts to separate the joint surfaces and elongates the surrounding soft tissues. Spinal traction is used to distract joint surfaces and stretch soft tissues. Joint distraction is defined as the separation of two articular surfaces perpendicular to the plane of the articulation. For distraction to occur in the spine, the force applied must be great enough to cause sufficient elongation of the soft tissues surrounding the joint to allow the joint surfaces to separate. Smaller amounts of force will increase the tension on or elongate the soft tissues of the spine without separating the joint surfaces. A force equal to 25 percent of a person's body weight has been shown to be sufficient to increase the length of the lumbar spine; however, a force equal to 50 percent of a person's body weight is necessary to distract and separate the lumbar vertebrae. A force of seven percent of total body weight is sufficient to distract the cervical vertebrae, according to one study, while 25 pounds is necessary according to another study. To be considered for coverage, traction must be medically necessary and the following documentation must be present in each treatment note: Part of the body to which traction is applied Force of traction applied (pounds) and angle of pull Amount of time the traction is applied Normally a trial of five to eight treatments in the clinic is allowed to determine the efficacy of traction and then continued by the patient in the home with the use of a home traction unit. Equipment and tables utilizing roller systems do not perform traction as defined above; therefore, the Physicians' Current Procedural Terminology (CPT) code should not be used to describe services using this equipment. Services utilizing roller system equipment are non-covered Participating Chiropractor Manual January 2005

21 Shortwave, Microwave, Diathermy Treatments and Ultrasound (CPT Codes 97020, 97024, and 97035) These modalities require the skills of a qualified chiropractor and may be covered if contract language and medical necessity criteria are met. When performing a combination of ultrasound and electrical stimulation, only should be billed. Providers may not bill CPT code with CPT code for the combined modality. Therapeutic Exercises and Neuromuscular Retraining (CPT Codes and 97112) These modalities are covered if required due to the skill of the exercise and the condition of the patient. After a patient has been instructed in an exercise or exercise program, the repeated performance of these exercises in the clinic, even under the supervision of a chiropractor, are considered non-skilled and non-covered. Patients performing exercises independently, and the use of exercise equipment not requiring hands-on treatment and the skill and expertise of the chiropractor, are non-covered. The use of CPT code can be billed for impairments of the body s neuromuscular system. Gait Training (CPT Code 97116) Evaluation and training provided to a patient whose ability to walk has been impaired by neurological, muscular or skeletal abnormality may be covered provided it could reasonably be expected to improve the patient's ability to walk. Exercises to improve gait, maintain strength, endurance, and assist with walking for feeble or unstable conditions do not require the skills of a chiropractor are not covered. Therapeutic Massage (CPT Code 97124) In order to be considered for coverage when billing therapeutic massage [Physicians' Current Procedural Terminology (CPT) code 97124], the massage must be performed by a chiropractor. Massage therapists, exercise physiologists, physician assistants, registered nurses, licensed practical nurses, athletic trainers, other assistants, and office personnel are not considered as providers eligible for coverage. Therapeutic massage must be of a skilled nature and must be part of a specific, diagnosis related goal. The services must be of a level of complexity and sophistication that they require the skills and expertise of a chiropractor. Massage performed with hand-held devices such as vibrators is not considered skilled in nature and is not reimbursable. Manual Therapy Techniques (CPT Code 97140) The following guidelines must be met for coverage consideration: Mobilization should not be billed when a manipulation is performed to the same area. CPT codes and should not be billed on the same date of service. Treatment must be diagnosis related and documentation must support proper billing of CPT code and contain the following: Description of specific area treated Soft tissue technique utilized Response of patient to treatment Treatment must be performed by a chiropractor Participating Chiropractor Manual January 2005

22 Non-Covered Services Several procedure codes in the physical medicine range are treatments that do not ordinarily require the skills and full attention of a chiropractor and are non-covered. In cases where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, or other complications, these modalities may require the skill of a chiropractor. If such treatments are given as a prerequisite to a skilled physical medicine procedure, they are considered part of that modality and are not separately reimbursable. Examples of these services are hot or cold packs (CPT code 97010), whirlpool baths (CPT code 97022), infrared treatments (CPT code 97026), Hubbard tank (CPT code 97036), hydrocollars and hydrochairs. The following services do not require the skills of a chiropractor and are not eligible for reimbursement: Repetitive exercise to improve gait, maintain strength and assist with walking such as that provided in support for feeble or unstable patients; Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are used in maintaining range of motion in paralyzed extremities; or General or weighted exercise programs and aerobic conditioning. Chiropractic Manipulative Treatment (CPT Codes ) CPT codes may be billed at each visit, but may not be billed in conjunction with an office visit or any other evaluation and management code. These codes include a pre-manipulation assessment (palpation, etc.) and a post-manipulation assessment. It is appropriate to use to describe Chiropractic Manipulative Treatment (CMT) to one or more extraspinal regions, regardless of how many individual extraspinal manipulations are actually performed. CPT can be used either by itself or in conjunction with a spinal CMT code. There are five extraspinal regions: head (including temporomandibular joint and excluding atlanto-occipital region); lower extremities; upper extremities; rib cage (excluding costrotransverse and costovertebral joints) and abdomen. Documentation of pain alone is insufficient to support the billing of CPT code There must be enough diagnostic information to support the treatment of the extraspinal segment. Documentation of all CMT s should include the following: Subjective record of the patient complaint. Physical findings to support manipulation in a region or segment. Assessment of change in patient condition, as appropriate. Record of specific segments manipulated. Radiology Services Radiology codes should be billed once per treatment period. If additional codes are billed, these services will be subject to medical review for documentation of medical necessity. Participating Chiropractor Manual January 2005

23 New Patient vs. Established Patient Office Visit Coding Our policy on the definition of new patient vs. established patient mirrors that of the American Medical Association s Current Procedural Terminology Book (CPT-4). A new patient is one who has not received any professional services from this provider or another provider of the same specialty who belongs to the same practice, within the past three years. This patient is one whose medical and administrative record must be established. An established patient is one who has received treatment from the practice within the past three years, and records are available to the provider. Office and medical services for new patients, CPT codes , should be filed one time by the same provider for the same patient. If filed more than once, the allowance will be based on the level of service for an established patient, CPT codes Chiropractic office visits are generally coded as one of the following: Office or other outpatient visit for the evaluation and management of a new patient that requires these three components: 1. a problem focused history; 2. a problem focused examination; and 3. straightforward medical decision making. Typically, 10 minutes is spent face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient that requires these three components: 1. an expanded problem focused history; 2. an expanded problem focused examination; and 3. straightforward medical decision making. Typically, 20 minutes is spent face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient that requires these three components: 1. a detailed problem focused history; 2. a detailed problem focused examination; and 3. medical decision making of low complexity. Typically, 30 minutes is spent face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient. Typically five minutes are spent performing these services. Participating Chiropractor Manual January 2005

24 99212 Office or other outpatient visit for the evaluation and management of an established patient that requires at least two of these three key components: 1. a problem focused history; 2. a problem focused examination; 3. straightforward medical decision making Office or other outpatient visit for the evaluation and management of an established patient that requires at least two of these three components: 1. an expanded problem focused history; 2. an expanded problem focused examination; 3. medical decision making of low complexity. Although codes do exist for higher office visit levels than 99213, it would be rare for a chiropractor to perform the complex levels of medical decision making to justify the use of the code. For assistance in determining the level of history, examination, and medical decision making, please refer to the documentation guidelines in the beginning of the Evaluation and Management Services section of the CPT code book. Codes may only be used once per office visit and may be appropriately used when a documented change of condition requires a re-evaluation of the patient or when manipulation is not performed. If a manipulation is performed, and there is not a documented change of condition or re-evaluation, CPT codes should be used. A chiropractor should not bill for an office visit and a manipulation on the same patient for the same date of service even if the patient is being seen by the chiropractor for the first time. Codes may be used only on the initial visit. Standards of Documentation The patient s record must be sufficiently complete to provide an accurate portrayal of the patient s clinical presentation to another health care provider. Physical medicine and chiropractic treatments must be documented by the person rendering the service. If a treatment is co-signed by eligible personnel but rendered by non-eligible personnel, it is not eligible for reimbursement. The signature must be legible. Signature stamps are not acceptable. The medical records should contain the patient s name and the date of service on each page. Initial Evaluation The purpose of a new patient or initial evaluation is to determine a diagnosis, set up a treatment plan, determine a prognosis, and to refer to a physician, if indicated. Documentation for this initial visit should follow a Subjective/Objective/Assessment/Plan format (SOAP) in that it should clearly present all subjective and objective findings, as well as a general assessment of the patient's present condition and a plan for future care. It should include a complete history and physical examination and a specific orthopedic and neurological examination directed to the area of involvement. Radiology findings should also be included. If applicable, we should see a plan for home treatment outlined at this time. Participating Chiropractor Manual January 2005

25 Re-evaluations If adequate progress cannot be documented by about the sixth visit, a re-evaluation should be performed. This re-evaluation should contain documentation of subjective and objective symptoms, findings during your assessment, previous modalities, and future plans. It should focus on the current status of the patient and the changes, if any, that have occurred since his/her last treatment. If no specific progress has been documented by the 12th visit, the patient should be either referred to another chiropractor, a doctor of osteopathic medicine (D.O.) or a medical/surgical physician for further development or diagnostic testing. At this time, a symptomatic patient should be re-evaluated to define whether their symptoms are from an exacerbation, a re-injury or a new diagnosis requiring a different course of treatment. Progress Notes Progress notes or treatment notes should contain the same information as is outlined above. Also, they should focus on the current status of the patient and the changes that have occurred since the last treatment. Bar scan and other such computer-generated notes are often inadequate when used as a sole source of documentation. For services to be reimbursed by Blue Cross and Blue Shield of Alabama, there must be eligible plan benefits, a documentable rationale for the plan of care ordered and a reasonable expectation that the treatment provided will produce significant improvement in the patient's condition in a reasonable and generally predictable period of time. All submitted documentation including initial evaluations, plans of care, and treatment/progress notes must be written and signed by the person performing the hands on treatment of the patient. Credentials must accompany the signature. Unsigned documentation is not accepted. Precertification Many Participating Chiropractor Benefit Agreements have specific limits on coverage for chiropractic services. It is very important to review each patient s specific benefits online to determine what the limits or precertification requirements are. For Participating Chiropractor Benefit Agreements with no specific limits or limits greater than 18 visits per calendar year, precertification is required between the 12 th and 18 th visit if the chiropractor feels the patient's care will require more than 18 visits. If precertification is not obtained, coverage for all services associated with the 19 th visit and subsequent visits will be noncovered and the patient will be held harmless. Patients may be billed if, prior to services being rendered, a non-covered statement is signed indicating the patient has been properly informed that the services to be rendered are not covered by their Benefit Agreement and that they will be responsible for paying for the services. For more information on non-covered statements, see the subsequent examples in this manual. Some contracts may have other specific limits on the number of visits allowed prior to precertification. It is of vital imporortance that the patient s eligibility and benefits be reviewed for requirements that differ from the above generalities. Participating Chiropractor Manual January 2005

26 When filing for a precertification, a completed precertification form and all required information including plan of care and rationale information must be received prior to the 18 th visit for future care to be covered. All requests and information for each individual patient must be sent in separate faxes. Click here to view the Chiropractor Certification Form. You will be notified of the results via fax, so be sure to include your fax number. If no fax number is provided, results are sent via standard mail. This information can be mailed to the address below: Blue Cross and Blue Shield of Alabama Health Management Attention: Chiropractic Precertification Post Office Box Birmingham, Alabama Fax Number: Maintenance Care Maintenance Care is defined as management of a patient who has reached pre-clinical status or maximum medical improvement where the condition is resolved or has become stable. It is characterized by repetitive services that do not require the use of complex and sophisticated procedures and most likely could be performed by a non-clinical person. Significant changes in a patient's condition, pain level and/or function should be re-evaluated and continued aggressive care needs should be documented before reimbursement can be made. Re-education and reform of home or current treatment should be handled during this re-evaluation. Criteria for Benefit Coverage To be approved for coverage, the services filed must be medically necessary, adequately documented in the medical record, within the scope of practice for the provider rendering the care, and within the patient's contract limitations. Likewise, if the medical record does not reflect the level of service, manner of service, medical necessity of that service, or is not legible, no reimbursement will be made. Appeals of Determination Not to Certify Additional Visits If services are non-certified, you may request an appeal. The appeal process is outlined below. Your appeal will be assigned to a person who is neither the person who rendered the original non-certification decision, nor his subordinate. We will consult a health care professional who has appropriate expertise and who is qualified to render a clinical opinion about the medical condition, procedures and treatment under review. This person will hold a current and valid license in the same category as the ordering provider, or is a doctor of medicine or a doctor of osteopathic medicine. If we consulted a health care professional during our non-certification, we will not consult that same person during our consideration of your appeal. We will consider your appeal fully and fairly, without deference to the non-certification. Participating Chiropractor Manual January 2005