Dynamic Chiropractic – October 8, 2007, Vol. 25, Issue 21

Billing for Unusual Procedures or Services

By Samuel A. Collins

Q: I have a patient who is morbidly obese, wheelchair-bound and relying on oxygen assistance. Due to this, I have great difficulty in delivering my chiropractic adjustment, getting the patient on and off the adjusting table, and positioning the patient during the manipulation service.

Is there another code I can bill to account for the added work for this patient? I am aware that chiropractic manipulation is not timed and cannot be billed in units, but I am hoping there is some other way to code for it.

A: Your question is not typical, but is certainly reasonable for a patient with these disabilities, as it will be more difficult and require much more time, effort and expertise to deliver your chiropractic adjustment. You are correct in your assessment of chiropractic manipulation (CMT) not having a time component. While there is no additional CPT or HCPCS code to account for this, there is a modifier that can be appended to the manipulation code to indicate the unusual circumstances. This modifier also will increase the value of the service.

The modifier is -22, Unusual Procedure or Service. For example, with respect to your patient, the CMT service may be coded 98940 and have modifier -22 appended, in order to demonstrate the unusual needs and expertise for the treatment of this patient. This modifier is to be used only when additional work factors requiring the practitioner's technical skill involve significantly increasing clinician work, time and complexity. It is generally accepted that the work time should be increased by at least 25 percent, although some carriers will expect to see as much as 50 percent to justify the use of the modifier. The unusual circumstances, work and time must be recorded in the patient's chart notes. The modifier will increase the value of the service by 50 percent, and your pricing on the billing should reflect this increased cost. My recommendation is to submit a short note indicating the specifics predicating the use and need for the modifier.

This code is acceptable for all types of claims and is not limited to a specific insurance plan. It typically would only be used in a chiropractic office for the CMT service and should not be used on codes that have a time component, as the added time is easily valued by the use of multiple units. It also is not appropriate to use it for evaluation and management services (99201-99205 and 99211-99215).

The modifier -22 should not be used on a routine basis and is not intended to augment specific chiropractic techniques, doctor's style or method. Please note this is not for a doctor who simply spends more time on the treatment based on method or style. Instead, it is based on the specific needs of the patient. If this modifier is used more than in 1 percent to 3 percent of your total claims, be prepared for an audit of the claims. Of course, an audit does not mean the claim is improper, but you must be able to justify it.

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