What's the definition of an Office Visit and Can I Bill it With a Chiropractic Treatment?

January 18th, 2018 - Brandy Brimhall, CPC CPCO CMCO CPMA QCC
Categories:   Compliance   Modifiers   Billing   Evaluation & Management (E/M)  

Question

Can you please help me with the definition of Office Visit? We have used code 99213 E&M code for office visits. However, we have some insurance companies that will cover office visits but not chiropractic treatments. Can we bill for office visits even though we are giving chiropractic care? And, is code 99213 a good code to use for an established patient visit? Providence Health here in Oregon did not like us billing 99213 and using M99 codes along with this CPT code. They still consider it chiropractic treatment. Which it is but we did not use a CMT code. We charge a flat fee for office visits/treatments.

Answer

If you bill for an office visit on the same date as chiropractic treatment, you must append the 25 modifier to the office visit/exam code.  On this note, you must be sure that you are indeed performing a "distinctly separate" office visit, in order to bill and collect payment from this as a separate procedure.

Bear in mind also that there are different levels of E/M and you must be careful to have appropriate documentation so as to select and bill for the proper level of E/M.  I would encourage you to review the 1995 E/M guidelines so as to gain a greater understanding of these requirements.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

M99 codes are appropriate to support the 9894- codes for chiropractic manipulative treatment.  This is so unless the payor specifically identifies other diagnosis codes instead.  M99 codes would typically not support the E/M codes.

Note that many policies limit the number of office visit E/M services allowed to be billed so you must also verify benefits to ensure you haven't exceeded those limits.  Here are some detailed descriptions of the codes we are discussing:

25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service:It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

99213Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99212Office or another outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

###

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)

What’s Going on with the COVID Vaccines Now?
May 4th, 2023 - Wyn Staheli
Keeping up with the changes to the COVID vaccines has certainly been a rollercoaster ride and we now have two new twists to this exciting ride. Buckle up and let’s look at how this changes things.
Reporting Modifiers 76 and 77 with Confidence
April 18th, 2023 - Aimee Wilcox
Modifiers are used to indicate that a procedure has been altered by a specific circumstance, so you can imagine how often modifiers are reported when billing medical services. There are modifiers that should only be applied to Evaluation and Management (E/M) service codes and modifiers used only with procedure codes. Modifiers 76 and 77 are used to identify times when either the same provider or a different provider repeated the same service on the same day and misapplication of these modifiers can result in claim denials.
Five Documentation Habits Providers Can Use Implement to Improve Evaluation & Management (E/M) Scoring
April 11th, 2023 - Aimee Wilcox
Provider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.
Second Quarter 2023 Updates are Different This Year
April 6th, 2023 - Wyn Staheli
The second quarter of 2023 is NOT business as usual so it is important to pay attention to ensure that organizational processes and training take place to avoid mistakes. Not only have ICD-10-CM coding updates been added to the usual code set updates (e.g., CPT, HCPCS, ICD-10-PCS), but the end of the COVID-19 Public Health Emergency will bring about changes that will also take place during the quarter (but not on April 1, 2023.
7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth Fraud
March 28th, 2023 - Aimee Wilcox
A recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?
MUEs and Bilateral Indicators
March 23rd, 2023 - Chris Woolstenhulme
MUEs are used by Medicare to help reduce improper payments for Part B claims. This article will address the use of the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) and how they are used by CMS.
It is True the COVID-19 PHE is Expiring
March 16th, 2023 - Raquel Shumway
The COVID-19 PHE is Expiring, according to HHS. What is changing and what is staying the same? Make sure you understand how it will affect your practice and your patients.



Home About Terms Privacy

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

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association