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Editor's Note: The following letter was submitted to DC and Sam Collins, who authors the "Ask the Billing Expert" column every issue.

Billing for Manual Therapy Techniques: Proper Use of the 97140 Code

Dear Mr. Collins:

I read your article in the Nov. 18, 2008 issue of DC regarding the billing of code 97140, manual therapy techniques. This code has been very controversial, to put it mildly, for most chiropractic offices. We follow the rules and the insurance companies will "interpret" those rules to their favor, no matter how erroneous their interpretation is. The 97140 code is the perfect example of that.

First of all, in your article, you requested that all chiropractors "be very specific on documentation from their 97140 services. If they are not to a separate region from manipulation or a different date of service, do not bill separately for that service." I have enjoyed your articles in the past and they have been on point; however, I believe that you are now bowing down to the insurance industry's erroneous interpretation of the 97140 code. I can tell that you are using the insurance company's perspective because you use the term region, which I underlined previously for emphasis. This is a total misinterpretation of the code. Let me explain.

This code has been interpreted by third-party payers using the NCCI edits, which indicate what can be billed for Medicare. It doesn't matter if the provider adds modifier -59 to the 97140 code; the NCCI edits state that modifier -59 cannot be used. Third-party payers have used the NCCI edits to benefit themselves by denying payment for 97140, even though the CMS Web site states that the edits are for Medicare use only and that other third-party payers cannot use them.

However, a March 12, 2002 letter from Dr. Niles Rosen of AdminaStar Federal, a CMS-contracted carrier and intermediary, to Mr. D.H. Leavitt of the ChiroCode Institute, stated that chiropractors can, in fact, bill for CMT services on the same day as 97140 services: "In the current version of the NCCI (8.0), the modifier indicator for each of these edits is a '0,' not allowing use of the NCCI associated modifiers. In NCCI version 8.1, the modifier indicator will be changed to a '1,' allowing use of the NCCI associated modifiers when the two procedures of a code pair edit are performed at separate anatomic sites or at separate patient encounters on the same date of service."

Even though the term regions is not mentioned anywhere in Dr. Rosen's statement, third-party payers have interpreted "separate anatomic sites" to be "regions." However, when I called and spoke with Dr. Rosen personally on 12/18/07, he stated that this is, in fact, a misinterpretation and that what is meant by separate anatomic sites is 1) two separate regions (lumbar versus cervical); and 2) two separate tissue types (muscle versus bone).

Because of the latter meaning, chiropractors can use the 97140 procedure code with the modifier -59 attached to it and get paid for the procedure, even when the procedures are performed to the same region. For example, when a chiropractor performs myofascial release and/or trigger-point therapy and also CMT to the cervical region, the office can bill for both the CMT, 98941, and the manual therapy techniques, 97140 with modifier -59, because myofascial release is performed to muscle tissue and CMT is performed to bone tissue - two different tissue types.

This misinterpretation must cease. We as a profession must make our state and national organizations discuss this issue with AdminaStar Federal and ask them to release a statement that explains the proper and thorough use of the 97140 code.

Dwight C. Whynot, DC
Johnson City, Tenn.

Are We Devolving Into Physiotherapeutics?

Dear Editor:

I would like to submit some comments on the article titled "Managing Acute Ankle Sprains" by Dr. Mark Charrette [Aug. 26, 2008 DC]. It was a good description of the physiotherapeutic approach to sprain of this synovial joint. I was dismayed to see, however, no recommendation for manipulative cavitation of the joint. Having treated several hundred ankles during 33 years of practice - mostly football (soccer) injuries in London, England - I am convinced that manipulative cavitation of the ankle joint is crucial to rapid recovery and perhaps the most important component of treatment.

In the same way that manipulation benefits acute sprain of other synovial joints such as the sacroiliac and vertebral facet joints, it also benefits the acute ankle sprain. Until recently, physiotherapists have advised against manipulative cavitation of sprained joints, suggesting it caused further traumatization of the soft-tissue holding elements. As chiropractors, we know that this is a misperception and that the restoration of function (i.e., mobility) to the joint should take precedence over pain management. Consequently, we manipulate the acute facet joint or SI joint and note the rapid reduction in local inflammatory edema and associated pain, and the restoration of joint mobility.

It is also known that cavitation of the acute joint is accompanied by momentary pain, and frequently symptoms can be worsened transiently the following day - the chiropractic "reaction." This is due, of course, to the stretching of the already overstretched (sprained) supportive ligaments, which produces the reflex temporary increase in local muscle guarding. That is why manipulation of the acute joint must be of low amplitude (to minimize ligamentous stretch) and high velocity (to overcome the restrictive muscle spasm). This, one may recall, is the essence of a chiropractic adjustment.

Furthermore, for manipulative cavitation to be successful in acute sprain of a synovial joint, the vectors of the sprain must be taken into account. In the case of an ankle joint, if it is a plantar flexion inversion sprain, then a counter-strain manipulation must be employed. The talo-crural joint would be adjusted, therefore, in dorsiflexion and eversion, which in most cases is comfortable for the patient.

The PTs I have employed over the years are amazed at the rapid recovery of sprained synovial joints with traditional chiropractic adjustments in combination with physiotherapeutic measures. The rationale for manipulative cavitation of a sprained joint involves intra-articular pressure changes, drainage of the inflammatory edema and reflexes involving ligamentous and tendinous mechanoreceptors, which are basic to the practice of chiropractic.

Considering all of this, I was dismayed to note the absence of the definitive aspect of chiropractic treatment - precision manipulation of hypomobile joints - in Dr. Charrette's article. Are we devolving into physiotherapeutics to the detriment of our professional identity?

Peter A. Ford, DC
Sundridge, Ontario

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