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Dynamic Chiropractic – July 16, 2007, Vol. 25, Issue 15

What Are Bundled Services?

By Samuel A. Collins

Q: I have recently had a rash of nonpaid services; the reasoning statement on the EOB reported that the services were "bundled." What does this mean, and what do I need to do to get my services paid?

A: Bundled services indicate that the modality of the service is an inherent part of other treatment done on the same visit and should not be billed or reimbursed separately.

Hot packs are considered bundled with many services, as they may be inherent to the performance of the specific service. For instance, when a hot pack may be used to heat and relax a muscle to facilitate therapeutic exercises, massage and/or chiropractic spinal manipulation, the hot pack is part of the other services. In each of these three examples, the purpose of the hot pack was to facilitate the main service, not to stand alone on its own value. A common statement from doctors of chiropractic that supports this fact would be: "The hot pack makes the adjustment easier or hold better." In other words, the goal of the hot pack was solely to facilitate the adjustment, and not used for its own stand-alone therapeutic value.

In many instances, it is appropriate to bill separately for services that can be considered bundled. To demonstrate that it is appropriate, there must be a modifier appended to one of the codes to designate the separate nature of each service. One of the most common instances is billing for an evaluation and management (99201-99205 and 99211-99215) on the same date as treatment. For the exam to be paid and not bundled as part of the treatment, the exam must have modifier -25 to designate that an exam was done above and beyond the level of evaluation included in the treatment codes.

Another common example is the use of modifier -59. This modifier is to be used on treatment codes to distinguish separately distinct services. For instance, when massage (97124) is done with chiropractic manipulation (98940-98943), massage should be appended with modifier -59 to demonstrate the separate nature and need for massage, apart from the chiropractic manipulation. For example, when massage is not used just to relax the patient and make the adjustment easier, but to facilitate fluid exchange, reduce muscle spasm and reduce pain, it should be separately reimbursed. Thus, it would be reasonable to bill separately and use modifier -59.

This same modifier -59 also is applied to exercise (97110) and neuromuscular re-education (97112) when done with chiropractic manipulation. Note: Unlike manual therapy (97140), exercise, neuromuscular re-education and massage (97110, 97112 and 97124, respectively) do not require a separate region from the chiropractic spinal manipulation.

To ensure codes are not bundled, be mindful of the purpose of each service as separate and distinct. If a service's sole purpose is to facilitate or help the application of another service, chances are it may be a bundled service and not be separately reimbursed. Whenever you feel a claim has been improperly denied for bundling, it is worthwhile to send a letter appealing the denial by highlighting the specific separate need and application of each service.

Of special note is United Health Care, which will no longer pay for hot packs, which is congruent with Medicare regulations. But many carriers, if not most, will still pay separately for hot or cold packs. Aetna insurance also has recently begun bundling mechanical traction (97012) with chiropractic manipulation. As a consequence, if you have had this denial for Aetna claims, begin billing 97012 with modifier -59.

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