by Dr. Evan Gwilliam, VP for PayDC
March 13th, 2018
Question: I just received a note from an attorney regarding a patient who was rear ended about 40 mph and ended up with neuropathy in her upper and lower extremities. We treated her for about 3 months after previous care failed to give much relief. I used flexion distraction and deep muscle stimulation to break up adhesions from the injury and used the 97112 code of neuromuscular re-education. The insurance company said that code was not warranted for her spinal sprain diagnosis and denied all of the services. Do you know how I could justify it? It greatly improved her condition with each visit and the patient said we provided the greatest relief she received.
Answer: To justify 97112 you need to show that the patient has neurological damage. The code description includes the following:
Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Therefore, in order to justify the use of the code, you need to document things like loss of balance or proprioception or difficulty standing. To help you see the payer's perspective on this code, here is a copy of a policy statement from Aetna as an example:
This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception to a person who has had muscle paralysis and is undergoing recovery or regeneration. Goal is to develop conscious control of individual muscles and awareness of position of extremities. The procedure may be considered medically necessary for impairments which affect the body's neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity) that may result from disease or injury such as severe trauma to nervous system, cerebral vascular accident and systemic neurological disease -Aetna CPB 0325
So, beyond a sprain/strain, your case would be stronger if you documented loss of DTRs or vibration sense, foot drop, muscle weakness, etc.
Consider, rather than trying to support the use of 97112, that 97110 might be more appropriate if the findings are just loss of strength, ROM, and flexibility (i.e. no neurological damage). It may be easier to support and it reimburses almost as well.
Don't forget to clearly document the time since 97110 and 97112 are time-based codes. And remember that flexion distraction work is more appropriately billed as Chiropractic Manipulative Treatment. If the 'deep muscle stimulation' actually a passive type of electrical stimulation, then it would be more appropriately billed with 97014.
Thanks to Dr. Evan Gwilliam for this answer. Dr. G was the Vice President of ChiroCode for several years before he took on the role of Clinical Director for PayDC, a cloud-based chiropractic EHR and practice management software that was built with compliance in mind. Contact him at email@example.com if you would like to schedule a free demo.