July 8th, 2013
The ChiroCode Institute has received several inquiries over the last few months regarding a denial for 97140 (Manual therapy—such as myofascial release or trigger point therapy) when billed with 98940-98942 (Chiropractic Manipulative Treatment - CMT) on the same visit. Most payers follow Medicare’s guidelines for the use of this code, which states that it may be performed on the same visit as a CMT code, but not in the same body region. As long as this is documented and billed with the -59 (distinct procedural service) modifier, it is compliant with AMA and CMS coding guidelines, and both codes should be paid.
According to several of our ChiroCode Premium Members, Aetna has begun to routinely deny 97140 when billed with 98940-98942 with the explanation that it is “mutually exclusive”. This verbiage is used in Medicare’s National Correct Coding Initiative edits. However, according to the current edits, 97140 is not mutually exclusive to CMT codes. It clearly shows that 97140 may be billed with the -59 modifier when performed in a different area than a Chiropractic Manipulative Treatment (CMT). As a result of these denials, we provided several ChiroCode clients with a well-documented and referenced sample appeal letter, but some claims were still denied.
Effective March 1, 2013, Aetna's policy says that 97140 is not recommended for payment on the same date of service as CMT, even with a modifier. Aetna explained that the reason for this policy was that their audits revealed that of the Doctors of Chiropractic audited, ninety percent of the time when the -59 modifier was used, the service was performed to the same region. They also found that documentation was inadequate. Unfortuantely, as a result, those who use the modifier properly are not being reimbursed along with those who are guilty of improper -59 use.
The American Chiropractic Association (ACA) recently met with Aetna representatives to learn more about the problem. They learned that once claims are denied, providers can still submit them for appeal and payment with documentation showing 97140 is medically necessary and performed to a separate region. While initially the first appeals were being denied, reports are now being received from the profession stating that claims processing offices are now processing appeals.
It is very important that offices send appeals to Aetna’s appeals addresses, not to billing addresses. If providers are in an area where Aetna uses the software, NaviNet, appeals should be entered one at a time and the box for “any additional dates of service” should not be checked. These claims should be noted that 97140 was “performed to a separate area” and/or providers should work with local appeals center staff to check their preference on appeals submission. Generally, records will be required. Aetna is bypassing their normal appeals processes of modifier 59 and performing a unique clinical review for the appropriate use of the modifier. Because of this, it could be easy for claims center staff to confuse other rules about modifier 59. For this reason, Aetna has alerted their top claims staff to assist in making this a smooth process, and so far, reports are coming in that doctors are being treated politely and professionally. It is important to note that Aetna indicated when meeting with ACA that, "Just as we put the policy in place, it can just as quickly be removed if this situation improves." ACA and ChiroCode encourage the profession to show Aetna that Doctors of Chiropractic know the rules pertaining to modifier -59 and we look forward to the overturning of this policy soon.