Modifiers in Chiropractic Medical Billing

As per the recent study, it has been noticed that Blue Cross and Blue Shield (BCBS) given denials to chiropractic practices for the claims billed with modifiers. Companies that offer medical billing services identified that the majority of the claims were denied owing to the requirement of modifiers 25 and 59. According to the Explanation of Benefits (EOBs), the modifiers were utilized more than average or used improperly. In December 2017, the Illinois Chiropractic Society (ICS) announced that the cases they studied, the modifiers, and procedure codes were billed rightly as per the information of claims, but because of a code-editing feature introduced by BCBS claims were denied. This incident has pointed to the importance of the usage of modifiers for Chiropractic Medical Billing.

Proper utilization of modifiers can escalate reimbursement. If codes are billed without modifiers when it is required, the carrier will deny the claim with justification on the EOB of clubbing with another service. Normally, an Evaluation and Management service (E/M) is filed without a modifier. According to the American Medical Association (AMA), chiropractic manipulative treatment (CMT) (98940-98943) is a type of manual service to influence neurophysiological and joint function.

Modifiers in Chiropractic Medical Billing:

Modifier 25

Modifier 25 is utilized to show that this is an important, independently recognizable evaluation and management (E/M) service by the same physician on the same day. Modification of the E/M doesn’t assure you the reimbursement. There are insurance companies that won’t cover CMT and E/M on the same day. On the other hand, some will consider paying for a new patient (99201-99205) not for an old patient (99211-99215). Modifier 25 is only applicable to E/M services.

GA Modifier

This modifier suggests that the Advanced Beneficiary Notice (ABN) is on file and enables the provider to bill the patient if not covered by Medicare.

GY Modifier

Added to all services except the CMT for Medicare claims, as all services excluding Chiropractic Adjustment are not protected by the Medicare Program when provided by a chiropractor.

Modifier 59

Modifier 59 is utilized to show an important, separately recognizable non-E/M service by the same physician on the same day. Manual Therapy Techniques (97140) used by chiropractors is a common example of a non-E/M service. This comprises manipulation/mobilization and manual lymphatic drainage and manual traction-one area or more, every 15 minutes. As this coding (97140) involves modification, it can be updated with a 59-modifier if it is carried out on the same day as a change (CMT).

X-set Modifiers

In January 2015, CMS published additional subsets of the 59-modifier, i.e. XE, XS, XP, and XU-modifiers that may be used instead of the 59-modifier.

  • XE Separate Encounter: a service that is distinct because it occurred during a separate encounter
  • XS Separate Structure: a service that is distinct because it was performed on a separate organ/structure
  • XP Separate Practitioner: a service that is distinct because it was performed by a different practitioner
  • XU Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap the usual components of the main service

The Active Treatment (AT) Modifier

The Active Treatment (AT) modifier was designed to define the difference between active treatment and maintenance treatment clearly. Medicare pays only for active therapy and does not pay for maintenance therapy. Claims should contain a primary diagnosis of subluxation and a secondary diagnosis that replicates the neuromusculoskeletal condition of the patient. These are some of the commonly used modifiers in chiropractic billing.

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