Post Payment Audit Risk Associated with Massage Therapy Services in a Chiropractic Offices

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Hello, everyone. My name is Michael Miscoe with Miscoe Health Law and our ChiroSecure topic for today is some of the post payment audit risks associated with billing massage therapy services from a chiropractic office. In many post payment audits, this ends up being a very common issue. And for that reason, I thought it appropriate to put out some information will hopefully help you mitigate some risks going forward. Some of the fundamental things that you have to think about when we’re talking about massage is, first of all, coverage. And while many payers will “cover” massage therapy services, you have to be very, very careful as to when and under what circumstances they will cover it. Just because they cover massage therapy services doesn’t necessarily mean that they always do.

For example, in a chiropractic office, when you call to verify benefits, the presumption is that massage therapy services are going to be covered, but the carrier’s presumption is that the licensed chiropractor is going to be delivering the massage. So when verifying benefits, not only you have to verify that massage is covered as a general matter, secondarily, you need to verify whether it’s covered when performed by either a licensed, if they’re licensed in your state or where they’re not, a certified massage therapist operating under the direction of a licensed DC.

And that’s a very important question because you have to distinguish massage that’s being performed based upon the decision-making of the massage therapist, which usually is not covered, versus the massage that is performed under the decision-making of the chiropractor, which brings us to some of the delegation issues that are associated with massage therapy services in post payment audits. In many cases, when we look at the records, there’s an apparent delegation of massage. However, the chiropractor pretty much defers all the decision-making as to the where, how long, what techniques, what specific muscles to the massage therapist.

And as a general rule, when I see two or four units of massage being billed, and we’ll talk about the coding as a separate issue, fundamentally, I’m presuming a head, shoulders, knees, and toes massage, in which case the medical necessity issues that arise is that massage is often being performed in a number of areas beyond the complaint. And there are some other medical necessity issues as well. But fundamentally, when the massage therapist is determining where to perform the massage, how long to perform the massage, what technique to use, and all of those things, then we cannot argue that the chiropractor has properly delegated the massage therapist even to a licensed massage therapist, because the massage therapist is figuring everything out.

If you can only get paid for the massage by billing it under the chiropractor, this is an important problem. Because from the chiropractor, I need a specific order so that the massage therapist is only doing exactly what the chiropractor ordered. And usually that would probably be a 15 minute, maybe a 25 minutes, depending on the number of areas involved, 15 to 30 minutes. But when you see four units, it’s just almost impossible to justify that that much massage is necessary in the areas of significant complaint and functional limitation. Assuming the delegation is permissible, make sure the chiropractor specifically orders the technique, the location, the specific muscles to be addressed, and the duration of the massage, and stay away from a 60 minute or 30 minute massages as a general matter because they’re highly scrutinized.

Assuming you get past the delegation issue, next thing we have to deal with is the bundling issue. Because when a patient visits a chiropractic office, usually the chiropractor is going to perform manipulation and maybe some other techniques and massage 97124 is a component of manipulation. And so you put the 59 modifier on it, but when we look to the where of the massage, assuming that’s identifiable in the record, we find that massage is performed in the same areas that manipulation is performed. And while there’s a hyper-technical argument to indicate that the 59 modifier is justified where a payer has a medical policy, they often alter that rule a little bit or where they don’t have a policy, they’re just going to not accept that argument, and they’re going to demand repayment of the money anyway.

So be cautious. Understand that massage bundles is a component of manipulation. It’s usually performed as a preparatory component to manipulation or to enhance the therapeutic benefit of manipulation. And for those reasons, it wouldn’t be separately compensable or codeable anyway because it’s considered a component of the manipulation. Turning back to some medical necessity issues, the first problem is obviously performing massage beyond the area of chief complaint. So for example, a one hour massage usually involves an entire whole body massage, and I jokingly say head shoulders, knees, and toes. Unfortunately, the patient has neck and low back complaints. Anything beyond those regions wouldn’t be medically necessary, so all that time has to come out as a general matter.

And secondarily, we have to consider what specific therapeutic benefit is being served by the manipulation that is separate and distinct from the massage, separate and distinct from that or the manipulation or other therapies that are being performed. Now, I know patients like massage, and it’s a great way to keep patients compliant with their visit schedules. But if that’s why you’re offering it, you might consider either eating it or making it a cash service, realizing that fewer people will get it. But there’s really little point to generating a lot of income out of massage only to have to pay it back, because these are very, very difficult issues to argue with payers fundamentally because when they see two and four units, they’re thinking of comfort massages, massages that we all like to get, but that we could live without.

So be very, very cautious there. And let me roll back to the coding issue, one other thing that just popped into my mind. You can’t bypass the bundling problem with the coding and the 59 modifier by scheduling a massage on a different day. So we see the chiropractor three times a week and then on the off days, another three or two days a week they see the massage therapist. Part of most carrier’s policies relative to medical necessity where you participate, especially with the blues, is the obligation to render care in the most cost effective and least costly fashion. And by purposefully segregating the massage from the manual therapy by data service to avoid the bundling problem is not cost effective for them or the patient, because it exposes the patient potentially to additional copays.

That’s not a solution. So for those of you who are sharp thinkers and think, well, we’ll just do them on different days, bad idea, because that shows up in data review as well. And the only reason to do different days is to bypass the bundling thing and carriers take a really, really dim view to that, and it makes settlement extremely difficult. Bottom line. I’ve done dozens, if not hundreds of cases where massage is involved. And they’re very, very difficult cases to resolve beneficially to the provider. Short of just simply not having the money to pay them back or going out of network or shifting to a non-covered service practice where you’re never going to submit another bill. Their arguments are very sound relative to massage.

The perception is that massage is done predominantly as a comfort service, and you need to be very, very cautious. If you are going to do one unit relative to do manipulation, do the separate region thing, make sure you justify why you’re not doing manipulation in the region that you’re doing massage. And finally, just remember, when you decide to code your massage as manual therapy, your massage therapist becomes unlicensed at that point. In which case, now the coverage issue and the delegation, some of them objected of having to pay for that because they’re not credentialed with the carrier as a participating provider and they slam the door on that pretty hard, usually demanding all the money back. So it’s a very, very difficult issue.

I know some practices do enormous amounts of massage have been faced with these types of challenges and had to shut down their entire massage operation, which was probably, in some of the cases, 60-65% of their clinic income. So they can have tragic effects. So be very, very cautious with massage coding it as manual therapy or neuromuscular reeducation is not going to help you because the billing pattern where they see manip, manual therapy, 97110, or I’m sorry, 140, 124 or 112, they see it in two or four units. They know it’s massage. And by miscoding it and doing things to disguise what it is can only lead to more difficult challenges in terms of your attorney’s ability to defend you in terms of recruitment. So be very, very cautious.

My advice, keep it cash or do it as a loss leader, let it bundle, keep it short and to the point, and you can keep your patients motivated without putting yourself in an insurance company’s crosshairs relative to massage, because it’s very, very highly audited and it’s one of the most difficult issues that attorneys like myself have to face in post payment review. I hope you find this helpful, and we’ll see you next time.

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