Blog, Chirosecure Live Event February 14, 2023

Ongoing Chiropractic Billing Issues with Massage

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All right. Good afternoon everybody. This is Michael Miscoe with Miscoe Health Law bringing you another addition of the ChiroSecure Growth Without Risk presentation series. What we’re gonna talk about today is some ongoing issues that I’m seeing lately with Providers billing, massage and manual therapy, either in addition to manipulation or some are trying to be cute and bill it separately on different days or they’re not even doing manipulation, but nonetheless Payers are picking up on patterns of billing where 3, 4, 5, 6 units of either manual therapy, CPT 97 1 40 or massage CPT 97 1 24 are being billed.

And they have a couple of issues with massage and my longstanding position on use of massage therapists. Is keep that cash because payers really don’t like it. I’ve done hundreds of post-payment cases with over massage therapy and they’re very difficult to no negotiate uber favorable settlements.

And when I say, very favorable, I’m talking five, 10 cents on the. These ones usually go 50 70 cents on the dollar in settlement, which means if you’re looking at several years worth of liability the numbers can get really enormous. So the first thing they’re the first problem that many payers have with either massage or manual therapy is.

The presumption that it bundles with manipulation and that presumption is either based upon an internal medical policy or an application of the national correct coding initiative edits that establish a component relationship between massage or manual therapy and manipulation. If you’re trying to do both massage and manual therapy on the same date one excludes the other.

So that creates a problem there. So with respect to this particular bundling issue, if massage or manual therapy is performed in the same body region, generally as how they interpret the CCI edit or how they write their policy, meaning, if you were doing. Let’s say trigger point therapy techniques in the midt trapezius in, you’re manipulating the cervical spine.

They would consider that in the same body region, and they would bundle it. Now under the N C I rules, technically that wouldn’t bundle for a very long, detailed explanation as to why but just understand technic. Coding issue is not withstanding re relating to the modifier 59 payers are gonna take the position that those services bundle usually.

The second problem that many payers have, and I’m experiencing this out in Michigan right now have a number of cases there where providers are getting challenged for their manual therapy billing or massage billing on the basis of. Now this becomes a very difficult argument. There’s a fundamental incident, two rule that allows physicians or other qualified healthcare practitioners to delegate either certain elements of a service or the entire service to a qualified auxiliary person who can be anyone from an assistant to another physician.

It has some. Sticky components to the rule. And that establishes the presumption or the fundamental premise by which payers will pay something billed under the physician, even though the physician either didn’t do all of the service or didn’t maybe do any of the service. So for example, consider the technical component of an mri, for example.

Nobody believes that the radiologist was in there running the MRI machine. So the entirety of the technical component is delegated to a technician and that’s permissible under what’s generally called the incident two rule. Now many payers adopt. Versions of the incident two rule, or don’t adopt versions of the incident two rule.

But when we’re talking about licensed massage therapist, we have to understand or evaluate what capacity the massage therapist is functioning in as a licensed massage therapist. Usually they are the recipient of referrals from a physician for massage therapy and under the scope of their license, they are doing the decision making to determine.

What massage techniques, where to perform them, how long to perform them and so forth. Usually they have an independent documentation obligation under their license, and those would be licensed massage therapist services. As a delegated service. However, their license really doesn’t matter other than to establish that they’re qualified to perform the techniques that you’re delegating to them.

So in a delegated scenario, the physician has to detail what techniques, where the services to be performed, how long it’s to be performed in detail, removing all decision making from the massage therapist. And then the massage therapist, simply to the extent that they have a documentation obligation, merely documents, performance of the manual therapy or massage service as ordered for fill in the blank minutes.

What messes up a delegation argument is when the massage therapist acts like a massage therapist, meaning they start writing soap notes and they’re doing decision making and look, they’re qualified to do it, but in a delegation scenario, all the decision making consistent with the fundamental requirements of the incident two rule have to be performed by the.

So you have to specifically order them what to do, where to do it and how long to do it. Now, that brings in some issues. Another issue the next issue that we’re gonna talk about is medical necessity. The normal one hour massage therapist, massage. Is what I like to call a head, shoulders, knees, and toes, massage and there’s some reflexology in the feet and, back, legs, hands, arms, ears, whatever.

The problem with that is, is that, The patient’s primary complaints, the complaints that established the necessity of the visit in the first place aren’t all over the place. And you shouldn’t try to document complaints all over the place just to justify a longer massage session. So you need to focus on the patient’s area of chief complaint.

They’re coming in with neck and upper back pain, neck and upper back. In which case I wouldn’t expect to see four units of massage or manual. That’s assuming you get past the bundling issue, which you probably won’t, but nonetheless, looking at it strictly from a medical necessity perspective, you have to identify those structures in that region, cervical, upper thoracic region that are problematic, and then order a specific technique.

To the massage therapist to not only satisfy the delegation rule but then also establish the medical necessity of that service. Okay. The last issue that we’re gonna talk about are the coding issues because, Licensure does not define what constitutes massage. So a licensed massage surface doesn’t necessarily do massage and their license isn’t necessarily restricted.

To the performance of massage therapy, just like chiropractic manipulative technique and osteopathic manipulative technique have nothing to do with chiropractors and osteopaths. Massage and manual therapy have nothing to do with P T O T versus lmt, when you look at the definitions and there’s another very long explanation for this delineation, but I’ll try to concatenate it into 30 seconds.

Massage is defined as fl petros to potent, which is compression, stroking, and so forth. Now, those techniques tend to be when you break down, those definitions tend to be more. Let’s say diffuse techniques where manual therapy techniques soft tissue mobilization, soft tissue manual traction those techniques massage therapists are usually licensed to do they’re licensed, usually stop short of joint mobilization manual traction of joints.

So they, they stick in the soft tissue world, but in that soft tissue mobilization, traction. Realm of manual therapy. You have techniques like myofascial release, trigger point techniques, things of that nature, which tend to be very focal, meaning they’re directed at a very specific portion of the muscle.

From that perspective, when you really study deep into the coding roles in the background and where these codes came from and all of that, which I of course have done the there is a difference and it doesn’t have anything to do with LMT and PTs, OTs, or dcs. When the coding of it, I don’t have a problem with coding, manual therapy or massage therapist service.

Properly delegated as manual therapy under the chiropractor assuming we get past the bundling issue. But the documentation has to demonstrate that it was actually a manual therapy technique or a lymph drainage technique and not, a more general effleurage, petros type technique that is consistent with the definition of massage.

Your biggest problem in the end especially when you’re billing four units and you’re consistently billing four units payers are looking at that as a, One hour comfort massage. And not medically necessary. So that’s gonna be the first problem. Delegation’s usually the second sometimes there’s coding issues and then eventually they’re gonna get to the bundling issue.

Now up in Michigan, they’re not raising the bundling issue cuz they don’t really think they need to go there. They’re really Huang up on the delegation and unfortunately, most of the records that I’m looking at, it’s just the patient’s getting massage and who’s decid. What kind of massage to give?

It isn’t the chiropractor and that eviscerates the doctor’s ability to bill those services legitimately under his or her name and NPI on the claim. And it’s given the payer a, a justifiable argument as to why they get the money back. Their fallback, of course, because it’s four units, five units, six units is gonna be medical necessity and they’re gonna win that one too.

And if they really need to then Drill down and go after the services that were performed in the same region as manipulation. Then they have the bundling argument now for one last point for the docs that think they’re being smart, but we’re gonna manipulate on this day and we’re gonna do massage manual therapy on this day, and we’re gonna break it apart by day so it doesn’t bundle.

Understand that with most commercial payers that you contract with also Medicare, although the issue doesn’t arise there. Part of medical necessity means you’re rendering care in the most cost efficient manner. And that’s not the most cost efficient way to do it. The most cost efficient way to do it is to do it on the same day and let it bundle.

And I realize that doesn’t get you paid, but that’s exactly the point. They’re trying to save money. You signed the contract and that’s what you agreed to. Be wary of that as well. Shorten to the. Billing for massage therapist is death on a stick. It’s probably the number one thing that payers go after in addition to some of the code pairs that we discussed either last month or the month before.

But this is one of the code pairs that they really target cmt. Manual therapy or CMT and massage or massage and manual therapy, God forbid, on the same date. If you’re billing a lot of massage and manual therapy in addition to your manip, you can count the days until somebody sends you a letter requesting records or wanting money back.

And depending on how well you’re documenting your delegations, whether you’re staying, how many units you’re billing, whether you’re staying focal to the area of complaint, all of those things will make. Let’s say a better argument for negotiating a more favorable settlement. That’s all we have time for today.

I appreciate your attention. Hope this was informative and helpful, and we’ll see you next time.