What modifiers are necessary on a chiropractic claim?

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Hey, good day, everyone. This is Sam Collins, your coding and billing expert for the HJ Ross company, chiropractic and ChiroSecure. Give you an update on some changes and coding and billing and reimbursement. Our goal with ChiroSecure is to empower your practice, empower you as a provider to make sure you’re getting paid, what you’re supposed to be paid and making sure that you’re accurately coding the services you are providing. Well, of course recently I’ve had a lot of offices with issues on modifiers. We offer a service called a network. When, when you join, I become part of your team and you can call me, email me with questions. Well, part of those questions that have really been hitting me over the last few weeks is what’s going on with modifiers Sam. I’m getting denials from let’s see VA, Oh, wait a minute. Also blue cross. And other changes have happened as of April 1st.

So where we want to make sure you’re up to date with all the use of modifiers that are common for chiropractic claims. So let’s get started, go into the slides. If you will. Let’s go ahead and start focusing in on what is changing and going. Please take special note with our company, email my email there as well as our website for all the information you need. We do offer a very good updated new section. I’m going to suggest all of you go in there. Just put your email. We’ll update you as things changes because the information I’m providing, we’ve actually put in there a few months ago as these things updated. Well, let’s talk about modifiers, CPT, modifiers, specifically, or modifiers. What are they to do? Modifiers are referred to as level one modifiers that are used to supplement information about a claim. By example, you’re all familiar with like using modifier 25.

It’s there to tell them that the exam is separate. So really modifiers, just do additional things to allow us to know something about the code. Remember there always two characters. Sometimes they are numbers. Sometimes they are letters now. So modifiers don’t typically alter the payment. It doesn’t increase the fee. Doesn’t decrease it. But what a modifier does is to make sure the claim does get paid. So the modifiers go right in this section of the 1500 form notice there’s four spaces. Now some of you may be going back to when this code or when this form updated many years ago, why four spaces while I think it was an in anticipation of what we’re seeing now, which is this update to the use of different types of modifiers. So what I want you to see here is that there are four spaces for modifiers, and there could be instances where you may use all four, not typical, but could, I’d say it’s not uncommon though, for a chiropractor to use three, but what’s the most common chiropractic modifier.

Well, that’s going to be modifier 25. This is old hat. What is modifier 25 it’s to demonstrate that the exam is separate from the treatment. Anytime you build any type of treatment, you must indicate that the exam is above and beyond. This modifier indicates that it’s a separately identifiable service. In other words, the treatment itself includes a little bit of exam. By example, on the first visit with someone you’re going to do a very detailed exam. That of course is appropriate. And you build an exam with modifier 25. Well, let’s talk about a follow-up visit on a follow-up visit. I’m pretty sure you’re not going to tell the patient, Hey, how are you doing? Shut your mouth, lay down and start adjusting. What are you going to do? You’re going to, Hey, how are you feeling today? You’re going to do a little review of history.

How is it better or worse? Probably do some palpatory findings, the other exam things. Now those are certainly an exam, but that level of exam is included in the treatment. So it’s not until you do one that’s above and beyond that, that we put the 25 and it’s the reason we don’t build an every day. So very common modifier. So how does that look? We’ll take a look here. Here’s a claim. Notice a mid-level exam nine, nine two Oh three. Notice because there’s an adjustment code. We put a 25, the absence of the 25 modifier would mean you wouldn’t get paid. They’ll say it’s included in another service. So make sure it’s always included. In fact, isn’t it interesting how most of you didn’t learn that in school, but yet that’s billing one-on-one so please make sure to pass it on. What about though, of course currently, are we dealing with telemedicine?

Well, what is the modifier for telemedicine? You know, that kind of like now? Well, it’s here is notice it’s modifier 95 for a telemedicine evaluation use modifier 95, not 25 because there is no treatment. There is a place of service, zero two. So 25 would be an exam with treatment, but a telemedicine visit would be modifier 95 places, service zero to, well, here’s some modifiers that we have a lot of problems with. Obviously the services of massage annual therapy. So-called bodywork a very common by doctors of chiropractic along with neuromuscular education. However, there’s a problem with these because there’s a modifier necessary. If without that modifier, you will not be paid. The most difficult part of these code with reimbursement though, is this, it must be performed to a separate region. Well, if it’s being performed to a separate region, of course it should be paid, but how do we make sure the insurance company knows it’s a separate region?

This is where we’re going to put either modifier 59 or S now you may think, well, which one should I use? Actually, they’re both fine to use. Technically the excess would be the better modifier. Modifier 59 says a distinct procedural services. And it says under certain circumstances, it may be necessary for a procedure service to show its distinct or independent. So hence the 59, you bill it to show it’s a separate service. Well, what’s actually better than that is modifier Xs. Modifier Xs actually is a subset of 59. And it’s more specific because notice what it says is a service that is distinct because it was performed on a separate structure. And that’s the difference with chiropractic in order to be paid for manual therapy, massage, ordinary must education. It must be performed to a region of the spine. You are not manipulating. So what would that look like on the client form?

Well, the look like on the claim form would be this notice gnosis I have highlighted in yellow radicular, apathy and myalgia. Notice the line with nine eight, nine, four zero has a B for pointer that AB is referring to this adjustment is being provided to the cervical region. Now notice massage nine, seven one two, four has excess and the two model and the two diagnosis codes, blue are low back pain and spondylosis of lumbar spine. But notice, it’s see, indeed, what are we indicating on this claim that the adjustment went to the neck and the massage went to the low back. That’s clearly separate regions and is payable. That is by far the best way. Cause often I’m sure you’ve run into, they will still deny it because often your computer program just puts ABCD, which of course means you’ve done it all to the same area.

Just be careful, do not adjust the same area or it’s not payable. So it has to be a separate region. And hence the use of modifier Xs, I would suggest the excess because 59 is probably the most over-utilized modifier. You don’t need a 59 outside of these codes. So be careful just throwing a 59 or an excess on everything. But with manual therapy, massage, same day as manipulation. Well here’s one that’s really become an issue. And recently many more payers are requiring it. It is modifier GP, which is called the always therapy modifier. Now this one’s a letter modifier, which means it’s a hip pick modifier HCPCS code, but is still a requirement. And according to CMS, they’ve adopted always therapy to go on any physical medicine codes. Now you’re going to notice there’s three modifiers here, GP G O N G N and may think, well, why do we use the GP?

Well GP, because as a doctor of chiropractic, you’re really doing physical medicine as an adjunct. So hence why we put a GP when it comes to physical medicine codes that G geo would be for an occupational therapist in G and first purpose. So therefore it would be, you know, where is this required? Well, it’s required on all physical medicine and rehabilitation services. So that means any of the physical therapy codes, which would be codes nine seven zero one zero through nine seven, nine, nine. And this included from last year, April of 2020 United healthcare and any affiliates. So that includes OptumHealth UMR in any of those. But in addition recently, it’s also required. Of course, if you’re billing VA claims also beginning this year, it’s required on blue cross blue shield plans of Michigan blue cross of California. Now be careful if you’re in California, not blue shield, but blue cross other States with blue cross blue shield include Indiana, Kentucky, Missouri, New Jersey, New York.

That means empire, of course, Ohio, Vermont, and Wisconsin. So if you’re not in one of these States, don’t just automatically add a GP. However, if you notice that a claim comes back and it says you are missing a modifier and it’s a physical medicine code, that is the likely reason. And you’re going to add that. We’re not sure if other payers are going to begin to adopt is something we’re going to watch. And it’s one of the reasons we do the network. We do these programs and we do seminars for that matter to make sure it was always up to date to make sure you’re getting paid. So again, for these payers, add the GP, don’t just throw it on everyone like Cigna or Aetna doesn’t require it. So Medicare also requires it. You might say, Hey, Sam, Medicare, doesn’t pay for therapies. We’ll hopefully in the near future.

But what about for Medicare? If you need a denial in order to pay for a secondary or a secondary to pay for it. So you would have to include all of those. So keep in mind, that’s a common modifier now, particularly for those plans. So you’ll notice here, notice twenty-five or excuse me, nine, seven one two four has the GP and the excess, but nine zero, just the GP. Excess is because a massage is being provided along with 99, four zero. Now notice something unique here. Notice nine, eight, nine, four zero has the aide designation, meaning the adjustment went to low back nine, seven one two four has the beat designation indicating the neck again, separate areas. Now what about other modifiers? These you’re probably familiar with, but they bear going over a little bit. Medicare has some unique modifiers and I think many times this is why providers are upset or frustrated with Medicare because you just don’t know the simple modifiers they require.

I will always say Medicare is not hard. Just unique. Once you understand the uniqueness pretty easy. So for Medicare, what modifier do you need? Modifier? 80 always goes on manipulation. When it is corrective care, meaning care you expect to be paid for. So simple rule is active or corrective care to Medicare always requires an 80. And remember that would be true also for Medicare advantage plans. Well, what else does Medicare use? Well, Medicare also uses modifiers, a G Y and GP. Now what does G Y G Y indicates it’s an excluded service meaning never covered. Well, remember what does Medicare cover for doctors of chiropractic only spinal manipulation. So real simple. What requires a GUI? Everything else. If it’s not spinal manipulation to Medicare, always put a G Y so notice nine, seven one one zero has a G. Why? Because it’s excluded, but then notice it also has a GP.

What does the GP to indicate physical medicine? So this is an instance where you would need two modifiers. Well, let’s go a little further. What if you were billing manual therapy, what did require a G Y a G P and N X S it actually was. That could be up to three. Now. What about this other modifier GA? Well, what if a patient wants to come in and goes, doc, it just feels really good to get treated. I like coming in once a week. I’m all in, but that would, of course to Medicare would be made. And Medicare does a lot, as long as the patient understands its maintenance. And that’s what this modifier means. GA the GA modifier indicates that the patient has signed. What’s called an advanced beneficiary notice or a waiver where they understand Medicare will not pay them. They’re responsible. So when billing to Medicare for maintenance care, put a GA on it, GA is very simple because you never will be audited for a GA.

Once the patient has accepted responsibility, you simply may build a patient. And in fact, under Medicare rule, it’s the one time you can build your regular fee. Medicare only controls the fee when they pay for it. Once it’s maintenance care, if you choose to, you can charge your regular rate. So Medicare requires an 18 modifier, manipulation, a GYN on every other service cause it’s excluded. But if it’s physical medicine, a GP, and if it is maintenance care, then G Y we are something unique. If any of you ever run into the Humana Medicare advantage plans, and this is one that’s a big, tricky, and I’m glad you’re listening in. I’ve had so many people go on. They’re not paying because they’re saying I’m missing a modifier. So they start throwing a 59 and a GP gets not what they require at all. You Manoj Medicare, meaning Medicare advantage requires modifier 97.

Take a look here. So if you get a Humana patient, quit the memory bank. Anytime you built an adjustment, spinal manipulation or physical therapy, you’re to put it in 97. So that’s you manna only don’t do that to anyone else. If you get a Humana patient Medicare advantage, here’s an interesting one. And I’ve had this come up. I’d have offices that have been part of the network and they call me and say, Sam, I had a patient that is under hospice and I build, and they wouldn’t cover it. Well, if you have a patient in hospice, you can treat them in. Medicare will pay. However, when they’re in hospice care, you have to add the G w modifier and that’s for services unrelated back pain or otherwise. So you would put this in addition to 80, for instance. So again, if you have someone in hospice, if you didn’t know that modifier not getting paid, here’s also one that’s come up.

Same. I want to take a summer vacation. I need to go away for a few weeks or maybe I’m sick. What do I do? Well, you can hire what’s called a locum tenants. And what a locum tenens is, is vacation relief or someone to come in just when you’re going to take a sabbatical. And when you build those services, you put modifier Q six. Now Q six, simply just indicates it’s a locum. Remember that billing just goes under your name, but that way identifies that you’ve brought in a vacation provider. And again, just allows you to make sure that you can do it up to 60 days. So 60 days is the max, but you certainly can. What if it goes over 60 though? What do I do? If you come back in the office, even for one day, the clock of 60 days starts taking again.

So again, for any extended time, that certainly could be a relief. Now, what about multi-discipline offices? And this is something that’s come up and I help a lot of offices with this. And when I say multidiscipline, it means M D D C, but remember MBDC is not always an MD. What about mid-levels nurse practitioners, maybe a physician assistant CMS has established two new modifiers, CQ, and C O. And what these are for, if you’re using a physical therapy assistant, you’re going to put a CQ on it. And the reason for that is that they’re doing that to identify when services are provided in an outpatient, by an assistant, and what it comes down to is that they’re going to pay at 85%. This became effective in 2020, but beginning to be enforced. Now, now, again, if you’re using a chiropractic assistant, this doesn’t apply, this is only for physical medicine, under a physical therapist.

When they’re using an assistant chiropractic, doesn’t worry about this, but again, in a multi-discipline office, if you have a PT and the assistant is doing the service, you’re going to add mom. So what could that mean? Would you have to put a GP and a CQ? Absolutely. So you can see here that this could be a little bit confusing, but without having the right type of knowledge, remember if you use this modifier 85%, as I mentioned, well, where do you get this knowledge? I do lots of seminars, continued education, and across the us. In fact, most of them are live and virtual. So take a look at our site, go and take a look. We offer lots of services to help you get paid, whether it’s a seminar, but we also offer a service, the network and what our offer to all of you. Take a moment, go to, in fact, let me move this forward, go to our website, or just to take this QR code, take your camera, hold it up to the site.

It’ll bring it right to the site. Give me a chance to be part of your team as a coding and billing expert. Why don’t you have someone like that on your staff? I can be part of your staff very easily, which means it gives you unlimited access to call email or fax me on any question. It could be a simple, Hey Sam, I need a diagnosis code, but more complex issues. I got a denial that says in one 23 or CLL 16, how do I fix it? My goal is every time you call will make back the money, it costs to join it. And I will assure you, we will that by tenfold. I’m going to thank you for the time today and next week we’ll have Mike Miscoe will be the guest. And I’ll say to everyone, I wish you well. And remember, it’s important to be a good person. It’s good to be important of course, but it’s more important to be good, be that to your patients and I’ll see you next time, everyone. Thank you very much.