How Many Modalities Are Too Many?

June 4th, 2018 - Dr Evan Gwilliam, Clinical Director for PayDC chiropractic EHR software
Categories:   CPT® Coding   HCPCS Coding  
0 Votes - Sign in to vote or comment.

Q:  I have a payor who is denying modalities, claiming that they are “excessive”.  At a single encounter I billed for:

  • 98940Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
  • 97110Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
  • G0283Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
  • 97010Application of a modality to 1 or more areas; hot or cold packs

Is this excessive?  How do I know how much is too much?

A:  First it is important to point out that modalities can be considered passive or active.  Some folks consider therapeutic procedures, like 97110, to be active modalities.  Others might say that modalities do not include therapeutic procedures, but that they are in their own category.  Regardless, many payors get worked up over too many of the same type of passive modality at the same visit.  For example: infrared, hot packs, and diathermy all at once.  That might result in a little overcooking.  But they tend to get more worked up over doing passive modalities like 97010 for 30 visits when 6-12 may be more appropriate.   

Here is a reference from a private payer that sums up the opinion of many reviewers:

  • The provider should attempt to integrate some form of active care. Continued use of passive care modalities may lead to patient dependency and should be avoided.
  • The utilization of more than 2–3 passive modalities per office visit is excessive and is not supported as necessary.
  • These rules hold true for acute, chronic and postsurgical cases. No matter what specific treatment is chosen, it must yield identifiable, objective outcomes to establish the necessity of care.

Passive modalities are most effective during the acute phase of treatment, as they are typically directed at reducing pain and swelling. They may also be used during the acute phase of an exacerbation of a chronic condition. The optimal duration of a course of passive modalities is a maximum of one to two months, after which their effectiveness diminishes, and patient dependency may develop.

Treatment plans for patients who are at risk for developing chronic conditions should de-emphasize passive care and refocus on active care approaches. When utilizing passive modalities after a lasting physiological benefit has been reached, the modalities serve only to facilitate the manipulation and are considered integral to the manipulative procedure.

Most uncomplicated cases can be adequately managed with spinal manipulation plus one or two adjunct modalities. Using more than two to three adjunctive passive modalities in one visit, in addition to joint manipulation, is considered excessive and not of proven benefit.

-Cigna Coverage Policy 0267 (emphasis added)

There are many helpful points in this policy, but it appears that Cigna would have no problem with a couple of passive modalities at a single visit, as outlined in the question above.  You may want to appeal that denial.  However, it would be wise to avoid doing these passive services at the end of care after they should have already provided their benefit early on.  A visit with both active (97110) and passive modalities (97010, G0283) would make the most sense in the middle of a care plan as a patient is transitioning from one stage of care to the next.  


This question was answered by Dr. Evan Gwilliam, Clinical Director for PayDC chiropractic EHR software.  If you are looking for an integrated, compliant, cloud-based solution to all of your scheduling, documentation, and billing challenges, look no further. Contact Dr. G to schedule a demo.  evang@paydc.com

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam
April 12th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273K
April 12th, 2021 - Wyn Staheli, Director of Research
Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments.
Properly Reporting Imaging Overreads (Including X-Rays)
April 8th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
hile many provider groups offer some imaging services in their offices, others may rely on external imaging centers. When the provider reviews images performed by an external source (e.g., independent imaging center), that is typically referred to as an overread or a re-read. Properly reporting that work depends on a variety of factors as discussed in this article.
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
March 31st, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
Understanding Skin Biopsy Codes
March 23rd, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
A biopsy is a procedure to obtain only a portion of a lesion for a pathologic exam. According to the AMA, "The use of a biopsy procedure code (e.g., 11102, 11103) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other ...
How Reporting E/M Based on Time May Lose Money
March 18th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
COVID-19 Vaccines
March 10th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
To accommodate the new COVID-19 immunizations the CPT editorial panel has approved 11 Category I codes. Watch for new and revised guidelines and parenthetical notes with these codes. For example; which administration codes should be used with the vaccine codes and the NCD codes applicable to the dose being administered. These ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association