As if it wasn’t difficult enough to receive proper reimbursement from some carriers, Aetna is throwing in another wrench in the process.  They are now ROUTINELY bundling and denying reimbursement for manual therapy (97140) when billed with a CMT code (98940-43).  According to Aetna, “there are very few indications for the application of manual therapy techniques, as described in procedure 97140, in addition to manipulation.”  SERIOUSLY?!?!?

Despite the denial explanation from Aetna, here are the facts about billing 97140 with a CMT code:

  • 97140 is NOT the same as a chiropractic adjustment.  According to CPT guidelines,  97140 describes “Manual therapy techniques.” Examples given are but is not limited to, mobilization/manipulation, manual lymphatic drainage and manual traction.  Therefore, if a chiropractor were to perform manual traction, a specific example given by the CPT, then coding it as 97140 would be entirely appropriate.
  • Chiropractic adjustments have their own set of CPT codes.  According to the CPT, chiropractic spinal manipulative therapy is represented by codes 98940, 98941, and 98942 .  CMT performed on an extremity is coded as 98943.
  • CCI Edits: According to CCI claim edits (CCI = Correct Coding Initiative), CMT codes (98940-42) cannot be performed in the same anatomical region as 97140 in order for both procedures to be reimbursable. This is called bundling.
  • Use of Modifier -59. There is a correct way to bill for both 97140 and your CMT on the same visit.  CCI edits dictate that 97140 is a “column two” procedure when combined with CMT, which means that the two are not mutually exclusive (that’s column one).  Instead, when these two codes are performed and billed on the same day, they require a modifier (-59) to indicate that they are separate and distinct procedures.  By using the modifier -59, you indicate to the payer that you understand the coding edits and that, in this circumstance, the procedures were distinct and performed in separate anatomical areas, Therefore,  both of these procedures should be payable.

Must Do’s when billing 97140 with a CMT:

In your notes:

  1. Your documentation must clearly show that your CMT was performed at a separate anatomical site from 97140.  Example: you adjusted the lumbar spine and performed manual therapy on the trapezius muscles.
  2. Your documentation should indicate the time spent for your 97140 work, as this is a timed service.

On your claim form:

  1. Modifier 59 should appear in box 24D on the line you billed 97140.
  2. Diagnosis pointing must occur in box 24E to show that the manual therapy was performed in a separate region than the CMT

What to do is Aetna denies reimbursement for 97140:

1. Make sure you properly code:  If your claim was rightfully denied because you failed to meet the conditions above necessary to have 97140 and your CMT paid separately, then you need to correct that right away.  Otherwise you are providing free care.

2. Appeal, Appeal,Appeal:  If you have properly filed your claim, you should be able to appeal each of these denials with your documentation. Appealing a payer’s decision is always an option for you unless you have specifically been told that no appeals are afforded to you for that claim. (Tired of creating appeal letters from scratch?  Check out our newly revised Chiropractic Appeals Solution.

3. Raise your voice:  Contact your state association.  I know several state associations are already aware of this situation.  Contact your national association.  Contact your insurance commissioner.  It’s also a good idea to get the patient involved.  Explain to them that the insurance company is not reimbursing properly which is causing them to have to pay for the care.