Blog, Chirosecure Live Event July 24, 2023

Questions From the Front – What about Massage Bundling & Billing?

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  We suggest you watch the video while reading the transcript.

Hello everyone. This is Michael Miscoe with ChiroSecure’s Growth Without Risk weekly presentation. And I have to apologize. I’m on the road this week in trial so I’m doing this from my hotel room and hopefully you allall can hear and see me well enough, but. This week we’re gonna take a question from the trenches.

Or occasionally I get emails from ChiroSecure insureds with some questions. And I thought this was a good one because I’ve been doing a lot of cases with respect to massage therapy. This particular member says I’m a 20 year chiropractor. SCU member recently took a part-time position in a massage therapy focus center.

As an independent contractor, we’re the massage therapists are employees to the center. None of the therapists nor the center has an N P I number, which means they would like to use me for the billing. I have a few questions. Okay, so immediately my antenna up because they are looking at this doctor as a billing vehicle in order to get third party reimbursement for what are no doubt.

Massage therapy services in the comfort realm. I like to call them head, shoulders, knees and toes massages. And unrelated to a specific condition. And so immediately we start thinking about The massage therapists are being performed at the direction and based upon the decision making of the therapist, meaning they’re choosing the technique, they’re choosing the location where they’re gonna work the client wants, I want you to focus on my neck or my low back, or whatever.

And they’re following that guidance. So from a fundamental perspective, at this point, these are massages that should be billed out under the massage therapist now. You may remember the massage therapists don’t have NPIs. That doesn’t mean that they can’t get them. Most likely if the massage therapist were to bill the services out under their name and n p i, they would not result in coverage.

So what they’re looking for is to bring this doctor of chiropractic in as an independent contractor and we’re gonna find out what they want this doctor to do. But fundamentally they’re looking for somebody to bill their services under. Okay, so the questions that the doctor has, if massage and chiropractic manipulation are seen as one and the same, then I’m understanding then what I’m understanding is either one or the other is to be used on a region.

Or to only expect payment for one, it sounded like they should be done together as massage is seen as a preparation for the manipulation, yet if not done together then to document why only massage was done. Okay. In this particular question, the doctors confusing. They are separate and distinct services without question and they have separate and distinct codes.

Getting that though.

The recognition that there’s some kind of bundling relationship between manipulation and massage, and there generally is. So from for payers that incorporate the national correct coding initiative, which is a reimbursement rule published by Medicare, there is in fact a bundling relationship between.

Manipulation and massage. Generally speaking a lot of hyper-technical arguments aside. If manipulation and massage are done in the same region then the massage would be considered a component of the manipulation and not separately reimbursable. To the extent, let’s just say for simplicity sake cervical, thoracic, lumbar region manipulation, that means all the muscles in the cervical, thoracic, and lumbar spine.

If they were to receive massage, most payers would consider that massage a component of the manipulation. Not separately compensable. The only way to get it paid would it be to put a 59 modifier on the massage. But if you do that, it will get you paid separately, but you’ll be paying that money back if the documentation demonstrates that massage was done in the same region as manipulation.

So that’s what the doctor’s getting at with this question. And as a general rule I would absolutely not recommend. Unbundling or separately reporting massage from the manipulation in that scenario especially where you’re a participating provider and the payer has a policy indicating that they either follow the N C I edits, or secondarily, they have their own policy with respect to separate reimbursement for massage in ation.

It’s not technically wrong, but I guarantee you it is a coating pair. That will get evaluated. And then you’re gonna run into the question to get the massage paid, you’re gonna have to bill it under the chiropractor who didn’t perform the service. There is a rule that permits that in certain circumstances, and we’ll talk about it in a second.

There was no discussion about a chiropractor providing the referral, which I’m curious about. If I’m an independent contractor, can I simply provide a referral with a diagnosis to the facility, which has hired me as an IC independent contractor? And if this is acceptable, would they simply have my name on the bill as the referring provider?

Okay. Now the chiropractor can in fact refer a patient for massage. And a massage therapist can exercise decision making and decide what to do and so forth. That service as a referred service, however, cannot be billed under the chiropractor. And while the bill in block 17, I believe, would refer to the chiropractor as the referring provider, the more relevant question is who is the rendering provider in Block 24 J or K, depending on which version of the claim form you use, whose name is in 31?

Now if it’s the massage therapist pursuant to a referral, that is correct. Billing. But like I said, it’s very likely that the massage therapist, even if they got their own N P I numbers, that a payer would pay them directly. There are some plans I have seen in different states where a massage therapist can get paid directly.

But they’re few and far between. Like I said, they’re looking for This Doctor Chiropractic looking to use that doctor’s n p I number to submit these claims as if that provider either personally performed the service or provided direction and control supervision consistent with what’s known as the incident two rule to allow billing.

Under the chiropractor, but then of course there’s a bundling problem. Now the issue with the incident two rule is that it requires the chiropractic physician to evaluate, diagnose, and specifically order the massage. That means, You know who, who to perform massage on where to perform the massage, what technique to use, and how long, so the, where is the specific muscles, the technique, if different techniques on different body parts that’s fine. But that all has to be specifically directed such that the massage therapist is exercising no decision making whatsoever. And even where. I’ve done a number of cases recently where payers can’t get in their mind that they can’t distinguish between a referral where the massage therapist does the decision making and a prescription where the chiropractic physician does the decision making and the massage therapist is essentially not functioning as a licensed massage therapist.

They become a chiropractic assistant at that point with . Specialized training in the performance of massage techniques. But nonetheless, payers are. Unwilling to recognize that distinction even when the record justifies it. Unfortunately, most records are not that precise with respect to the order.

So understand a referring provider. If you’re referring a service saying, Hey, go do massage on Sally Jones, then that service cannot be billed under you. Because you’re not performing the decision making with it, all you’re doing is passing the patient off to the licensed massage therapist. If you are ordering massage and you write a specific order, as long as the payer has adopted the incident, two rule.

Which allows you to bill a service under your name and n p i that you did not perform personally. And it has a number of components. It’s pretty much a 90 minute lecture. I don’t want to get into details, but the fundamentals are what I pointed out. You examine, you diagnose, you write a very precise treatment order, and the massage therapist only does what you tell them to do.

And if they believe that there’s some reason to change that, they have to come to you and get you. To write a new order. And then, and only then, and only if the payer adopts the incident Two rule. Can you bill that service under your name and N p i? But even if you do, if you’ve done a manipulation, then you’re, it’s gonna bundle anyway.

So you’re gonna go through all that aggravation. For likely no separate reimbursement. Which is why I roll back when we get to massage. Massage should always be cash in, in, in this scenario. The last question is, my only concern is that they don’t have an N P I at the center. I’m not sure if any of the MT massage therapists have an M P I number.

I’ll need to set up a an appointment to discuss so, Yes, the fact that they don’t have N P I numbers, but understand it’s, they can get they can get N P I numbers. The key is even if they had them and they bill under them, they’re not gonna get paid. So what this center is looking for and understand, this center is not a medical center.

It’s not owned by a chiropractor. It’s not owned by a medical doctor. It’s a bunch of massage. And it’s basically a massage therapy clinic. And they want to bring a chiropractor in so that they can start billing third party insurance. It’s a disaster waiting to happen. Now, the good news is the chiropractor as the Independent contractor.

Essentially if this was done correctly, the center would have to get an organizational N P I and then the chiropractor would have to associate his or her n p i with that organization. The organization would receive the payment. It’s the organization that would have to sign a contract with the Blues and Aetna and Cigna if they were.

Billing and network services, and it would be the center that would take the post-payment hit. What I suspect is that they wanna bill all this under the chiropractor. The chiropractor gets paid personally. And then what happens is if there’s a post-payment issue, it lands on the chiropractor, not the center.

And so this is a disaster waiting to happen. There were some follow-up questions with respect to referrals, and I think we addressed the difference between a referral and an order. But understand with massage you need to be very cautious because usually I. There’s not very many scenarios where it is separately reimbursable from a manipulation.

Some people try to do the manipulation Monday, Wednesday, Friday, massage Tuesday, Thursday, Saturday. Understand that where you participate, a core element of the definition of medical necessity is that the care must be rendered in the most cost effective and least costly setting, and it’s not cost effective to break up the visits like that.

And there’s. Usually no actual clinical rationale for doing it. The reason that you do it is because you want to get paid separately. Payers are very wise to that low billing scenario. They look for it. And it’s very easy to smoke out with data analysis. You don’t wanna do that if you’re billing.

Manipulation, A C M T 9 8 9 4 0 0 4 1 4 2 in addition to 9 7 1 2 4. The code for massage or billing your massages, manual therapy, 9 7 1 4 oh. Either one. The massage or manual therapy with a 59 modifier. In addition to the C M T, also a very highly audited code payer. So if you really want to get a payer’s attention just do that.

Somewhat routinely and I can pretty much guarantee you you’re gonna get a record request and followed shortly thereafter by refund demand. I hope that, if you are out there and you’re in the independent contractor realm, or even if you’re in a your own clinic, just be cautious about integrating massage therapy.

Yes, patients love it. Yes, it’s can be a way to help people stay current with their treatment plan, but do not look at it. From a third party reimbursement perspective as an extra service to get reimbursed for you should keep it cash. If patients want it, they can get it. If they don’t wanna pay for it, then they don’t get it.

And for those of you that have a bunch of massage therapists and all of a sudden you realize you’re gonna have to shut your massage therapy practice down from a third party billing perspective, and you’re gonna have a bunch of massage therapists sitting around twiddling their thumbs. Teach ’em how to do resisted stretching exercises and things like that where you don’t run into the bundling issue with 9 7 1 2 4 9 7 1 4 oh, but instead you’re doing therapeutic exercises.

Be precise as to sets reps. You have to tell them exactly what to do and then make sure that they’re qualified, consistent with your licensure regulations to do that. Some states do not permit the delegation of procedures. Some states, Don’t make a call one way or the other. So check your licensure rules and see if that is an option for you.

The great thing about massage therapists is they are familiar with the muscles so they know which, where their origins, insertions, and all that stuff are. And they usually can be taught some of these fundamental stretching techniques that are resisted, which is making, makes them active instead of passive.

Patients don’t like it as much, but in the long run I’ve had a number of clients say that it’s actually better from a restorative perspective in terms of helping people re regain their mobility quicker. So that is an option. But definitely check your carrier medical policies to look for bundling issues.

Check your licensure rules to make sure that you can use them in that fashion or any. Chiropractic assistant for that matter in that fashion. And but definitely avoid billing the C M T massage or C M T Manual Therapy code pairing because it is death on a stick. I’ve been done dozens and dozens of those cases this year, and it’s just unfortunate there where patients have certain plans and yes, they have massage coverage but when the payer sees it and pays it, it’s billed out under you.

Their expectation is that you personally did it. And they start doing the math in terms of how much massage you’re billing out and how many hours there are in a day. Plus they see it being billed in addition to manipulation, and they quickly figure out that there’s no way possible that you’re doing all this.

And if they don’t permit delegation then Then you may be looking at a refund demand. So that’s all we have time for today. I hope that was helpful. And next time, hopefully we’ll be back in the office in a regular venue. But until next time, everybody stay safe and be compliant. .