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Greetings, friends and colleagues, network members. This is Sam Collins for ChiroSecure, your coding and billing expert, the way to hopefully help your practice grow, thrive, and of course, always do a little bit more, a little bit better for you and for your patients. I wanna talk about this time around something that’s come up quite a bit for questions to me, particularly from network members and at seminars, and it’s Sam, how many services.
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Is reasonable. What can I get paid for per visit? How many, what’s the limit? Is there a limit? And I wanna get into that a little bit to make sure there’s a good understanding. Obviously it always comes back to medical necessity, but I do think it’s reasonable to start to understand what does a carrier look for?
What do we really consider reasonable? So let’s go to the slides. Let’s talk about it. Let’s talk about what is reasonable. For the amount of treatment per visit. Again, what should I do? Can I do six services, 10 services? How many units? What is going on here? What do I need to do? Let’s talk first about what things that we’re gonna do in chiropractic.
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Of course. I think the number one thing, and it’s almost a given, is you’re going to do a chiropractic manipulation. Now, it’s not always that you have to in order to do care, sometimes you may do a therapy only, maybe you will do. And examine no treatment. Other than that, however, most often are we gonna do a chiropractic manipulation, so absolutely.
It’s what we do that’s unique. I wanna emphasize that. Think of it as a patient. If I’m coming to a chiropractor, guess why I’m going? I want a chiropractic adjustment. It’s what makes it unique. If you think of it, why are we in chiropractic practice if what we’re doing is not unique? Because my goodness, if massage worked.
Why would we even be here if all these therapies, obviously chiropractic makes the biggest difference. In fact, if you look at most studies, in fact, I’ll say the latest studies on what is the best care for lower back pain. It highlights two things that are the best in combination, and that is chiropractic with meaning the adjustment.
With some type of active care exercise. Exercise alone is not as effective. This is part of the reason physical therapists will want to so much do manipulation. So bottom line is, of course, always a manipulation, not gonna be an issue. I think manipulation also fits during any part of the care plan, whether it’s at the acute, the chronic, the long-term, it’s gonna fit within that.
It really fits in any phase of it. However, let’s keep in mind, can you get paid for two manipulations in one day? No. If you manipulate someone twice in a day, that’s fine. Will an insurance cover it for two times a day? No. If you wanted to charge the patient for the extra, I guess you could, assuming you were out of network, so long as they understood that.
But for the most part, it’s gonna be one per day. So even if you try to go back with two, my dad being a chiropractor, I remember him often having a patient come in the morning and then he would tell them, Hey, come back in the afternoon. I wanna make sure this adjustment holds. He’d come back and he’d adjust ’em in the after he felt it held better.
Did he bill separately for it? Now. That’s just what he did. Now when it comes to the things I think I really wanna emphasize though, is how many of the services can we do a manipulation of course, is a given, but what about therapies? What is the limit? Can I do two or four? Let’s break them down and what types of therapies we’re gonna do.
I’d say the common therapy or modality, if you will, the passive care. Those you’re probably gonna do one per visit. They’re passive care. Think of it. What is the purpose of heat? Relax the muscles. Reduce pain. Okay. Increase range of motion. I like that ’cause the air is relaxed. But then what’s the purpose of electric stem?
Relax the muscles, reduce the pain, maybe some inflammatory changes. So you notice there’s a lot of duplication. So it generally you’re gonna, for a passive modality, you’re gonna do one per visit. In fact, I would caution, I wouldn’t even do two now, maybe if they’re to separate areas, so maybe you did electric stim to the knee, but then some other, something else to the neck maybe.
But you’re never gonna do two in one error, and that is something that definitely is always seen by insurance. If you do multiple passive modalities, they seem as duplicative. Meaning they’re doing the same thing. So the why. So when it comes to passive care, I’m gonna say one, and that would be about the max.
And remember those you don’t get billed for extra units. So it’s one maximum. Now the other therapies, of course, that we do are called procedures, or they’re active care, hands-on, if you will. Now, obviously that could include massage though. So is massage active care? It is, but it’s somewhat passive.
’cause if you think of it, what’s the purpose of massage? Muscle relaxation. Okay, pain management. So duplicates nonetheless. I do think it’s reasonable to have that. But hands-on procedures. What I wanna hit here is they are timed in 15 minutes. So therefore, depending on the amount of time you spend, of course you can do additional units.
So therefore, what’s reasonable? If you told me someone who was coming in and they’re getting massage, would 15 minutes be sufficient? In some instances, yes, but in others it might be 30 minutes. So it’s not unreasonable to do more. Now, to give you the highlight, there’s something we called the medically unlikely edits.
It’s things that can be done or the maximum that can be allowed for massage. Actually the maximum per visit per CPT, per a MA and per Medicare for that matter. I know we’re not paid by Medicare, but we’re talking under the maximum guidelines. They’re gonna say four to six units per visit. So you’re thinking, oh.
So would it be unreasonable in some instances if someone came in, they had a chiropractic adjustment, then four units of massage? I would say no. That’s a lot of services. Yes, that’s an hour plus. But nonetheless, is it reasonable? Is the purpose behind it? So therefore, what would I say is gonna be a maximum?
You’ll probably have heard this quite a bit. It’s probably about four services per visit. Now, where does that come from? Some insurance carriers actually limit that. We’ll get into that. But I would say four is about reasonable that there could be instances for more. Because what if you’re putting a person through some active care, and true active care like exercise.
Would anyone ever say, my God, I did exercise for 15 minutes. Man, that really worked. I’m in great shape. I don’t think so. This is why if you look at a physical therapy facility, they’re not doing 15 minute increments of exercise. In fact, it’s not uncommon for them to do probably an hour, 45 minutes, sometimes even more.
The maximum per exercise per visit that’s allowed is up to six units. Does that mean we need to do six? No, but it means that, could it be potentially reasonable if you give me the purposes, like if you’re doing a rehab post-surgical shoulder. Or knee, it may take that much considering the warmup, the actual exercise, the cool down.
Some things to reduce swelling. Yeah, that can certainly add up. What I’m gonna suggest is start to think along the lines of what is my purpose, but also what are the carriers expecting? Now, not everything is dependent upon insurance, but obviously if they’re paying the bill, we have to consider it. I’ll tell you, when it comes to Aetna, Aetna actually publishes, they’re gonna pay a maximum of four per visit.
Four. So you can do more than four, but they’re gonna push back. Now, could you potentially try to argue, hey, I little need a little bit more? Yes, but it’s not an argument I like to make, to always be on the upper end. I would say if you’ve got probably between an adjustment and two to three services or units per visit, I think you’re going to be fine.
I don’t think you should run into much issue again, so long as you can put together that purpose, the goal, the why. Now Anthem Blue Cross Blue Shield. A little bit different depending on the plans. There are some plans, and I’ll give an example. Blue Shield of California actually allows five therapies per visit, so a maximum of six.
Does that mean you need to do that many? No, but it does mean that it’s reasonable, or at least potentially reasonable. What I would say is always look at. What can I show as necessary? It’s not just, oh good, what’s the maximum? I can bill? One of the questions I get, Sam, what’s the most I can get? I get that there’s still a business end of this, but you always gotta think, what do I need to really effectuate this patient in the best way?
What’s gonna give me the outcome? And I would say, if you’re focusing on active care, it’s not unusual to see two units of exercise, maybe in a passive therapy on that visit. What about personal injury, though? Personal injury could be a bit more aggressive. Someone comes in with a pretty significant injury.
You may be doing a lot more care for that person. One, they have multiple areas, so I’m not gonna put an absolute limit to say that. Show me what’s reasonable. And again, I would say on average probably four services units per visit is fine. But can there be instances for more? Absolutely. Talk about severity, talk about multiple areas that can come into play.
You’ll see this comes back to making sure we can justify where you want to be careful is what if your bills are always on the upper end. Remember, pigs get fat, hogs get slaughtered. And it doesn’t mean that because you do more that’s necessarily a problem, but can you justify it if you always are shown to at a much higher level?
Is that gonna create more where someone wants to look at what you’re doing? Now, I’m not talking from just an insurance standpoint, but could the state board be involved? Absolutely. For those of you, obviously your malpractice helps to cover you. When it comes to audits, one of the things I deal with audits often is the board coming in saying, this provider has provided too many services per visit, or too.
Long of services because the patient has maybe made a complaint that could be an issue. But for personal injury, I would say certainly the patient probably is gonna be a bit more aggressive based on the number of areas, based on severity of course, too. But keep in mind also for that reason, there’s gonna be more.
But should there be a tapering probably as they get better work Conference instance, generally is gonna accept up to four services per visit. So again, privately in that range, what I would say the ultimate answer is gonna be, tell me the purpose. Tell me the why. If you can demonstrate why the person needs an hour and a half of massage and that fits, I’m gonna say, okay, maybe.
But start to think, does that seem reasonable? Just because something is a possibility doesn’t make it a probability. So I always think of what are my goals? What am I trying to accomplish? And I always emphasize active care. If you’re going to really strengthen a region, stabilize it.
Increased flexibility, strength, tensile strength if you will. Is that gonna happen in a 15 minute program? I’m not so sure. I’m gonna say probably 30 minutes. I’ve never seen anyone go into the gym going, wow, I worked out for 20 minutes and I’m doing great. As a starting point maybe. But I’m certainly gonna say, don’t be afraid to be aggressive.
Just make sure you always got your reasoning behind it. So to answer it succinctly, what I’m gonna tell you is if you’re doing probably. Four or less services or units per visit, you’re gonna be in a safe range if you bill above that. And I’m not saying not to make sure you’re gonna have more to justify, but realize even if you’re billing four, do you still have to go the why?
Not just because I like to think of what is the purpose of certain types of care if you’re doing passive care way into the course of care. I’m gonna question why. Why are we doing massage six weeks into care? Because if we’re still dealing with spasm. And we’re still dealing with the issues that massage is doing.
I don’t think our care is working. Whereas we’re gonna move it to the act or rehabilitation. And by the way, does rehabilitation pay a little bit better? It does. It has a higher RVU, and you’re gonna have less pushback. So keep in mind, when you’re doing care, look at yourself and go, does this appear reasonable?
Can I justify this? Or am I just a billing monster? Hey, I need to make sure I’m getting 200 per visit. I’m exaggerating that, but not really. There’s some offices that do bill that much. I don’t think it’s unreasonable. If you give the justification. Keeping the safe range if you’re doing an adjustment, two to three services, not much of an issue.
Just transitioning from passive to active I think is perfectly good. Just be mindful if you are billing more, you have more scrutiny. Be prepared. I’m not saying it’s ever wrong. Just make sure you have the data to support it. Nothing wrong with doing the care, that’s gonna help the patient. Show me a good outcome.
With that in mind, network members of course, always reach out to me, but if you’re not a member of the network, join make me part of your staff. I become part of your team. Let’s make sure your office is always thriving by having the right answers, the correct answers, so you’re always maximizing your services and of course your payments.
Until next time, my friends take care.
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