New coding that removes roadblocks to health care reimbursement

Be aware of the significant changes that occurred to DC E/M billing and coding for health care reimbursement at the beginning of this year

I HAD RECEIVED THE QUESTION, “About 9-12 months prior to the COVID-19 pandemic, I noticed my insurance reimbursements gradually decreasing. I provide high-quality care and help a lot of patients get better, however, I am not getting paid what I deserve. This becomes especially challenging knowing that I will not get paid more when I spend extra time with patients. I have also noticed that my cash patients are not paying their balances in a timely fashion and we need to send statements in the mail. Can you provide me with a few good strategies to remove these reimbursement roadblocks?” The answer? Yes. Here are two ways to overcome these obstacles and improve health care reimbursement:

2021 coding updates and new E/M guidelines

Approximately two years ago an initiative was introduced by the Centers for Medicare & Medicaid Services (CMS) called “Patients Over Paperwork.” The purpose of this program is to reduce the administrative burden placed on health care providers and their staff members and to also allow doctors to spend more time with patients. The new 2021 evaluation and management (E/M) guidelines allow chiropractors to spend more quality time with patients for increased reimbursement.

Significant changes occurred to chiropractic E/M billing and coding moving into 2021. The most common E/M codes reported by chiropractors are 99203 and 99213. As of Jan. 1, 2021, these codes along with the other new and established patient E/M codes (99202-99215) have undergone substantial revisions. Time and medical decision-making (MDM) are the two new key factors for exams and re-exams, replacing the previous guidelines that required three key components: history, examination and MDM.

The new guidelines allow reimbursement for the time you spend documenting the visit, reviewing MRIs and lab work, speaking with other health care providers, etc. It also allows for the inclusion of an independent historian. This is an individual such as a parent, guardian, surrogate, spouse or witness who assists with the history because the patient is unable to provide a complete or reliable history. This could be due to developmental stage, age, dementia or because a confirmatory history is needed. As long as the services are provided on the day of the encounter, they can be face-to-face or non-face-to-face. CPT code 99201 has been deleted, therefore the lowest level new patient E/M encounter is CPT code 99202 — even if the patient shows up with a minor or self-limiting problem (e.g., simple muscle strain).

The Relative Value Units (RVUs) have increased on most of the E/M codes. For example, one carrier has increased their 99213 allowable amount to $95 from $78.

dditional new codes

There are also new Prolonged Visit codes that became effective Jan. 1, 2021. Although not common, there may be instances whereby a new patient is seen above the maximum time range for the highest-level code of 99205 (60-74 minutes).

Have you ever spent 90 minutes with a new patient? Now you can get paid for the extra 15 minutes using new code 99417. This is a prolonged office or other outpatient E/M service beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time.

For example, for 89 minutes report 99205 and 99417 x1. For a 69-minute re-exam report 99215 and 99417 x1. There is an exception with 99417. If you’re going to bill Medicare Part B for secondary reimbursement purposes, you’ll need to use HCPCS code G2212 instead of 99417. Medicare has assigned a status indicator of invalid code to 99417 and replaced it with G2212. Most non-Medicare plans should be okay with 99417. Remember, as of Jan. 1 of this year, if you’re going to use time as the key factor instead of MDM, you can include factors such as reviewing records, documentation and the use of an independent historian.

New ‘PPE’ code

There is another new CPT code; I call it the PPE code. It is 99072 and this is for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a public health emergency as defined by law, due to respiratory-transmitted infectious disease.

This new code is designed to capture the following practice expense factors such as:

Time spent pre-screening patients before the visit and checking for symptoms on-siteApply and remove PPEPerform additional cleaning of the examination/procedure/imaging rooms, equipment, and suppliesCleaning supplies, including additional quantities of hand sanitizer and disinfecting wipes, sprays and cleansersReported only once per in-person patient encounter per provider tax ID# regardless of the number of services rendered at that encounterKeep track of and document the costs to your practice for the PPE, the additional staff time required for taking temperatures, completing questionnaires, etc., costs of additional cleaning supplies/materials required for disinfecting the office, additional staff time required for these procedures and additional janitorial costs associated with the pandemic

The AMA did not include any specifications regarding how to document this code. In their CPT Assistant article they refer to the definition of the code and note that “documentation requirements may vary among third-party payers and insurers; therefore, they should be contacted to determine their specifications.”

Sample 99072 SOAP Note:Additional time and materials above those usually included were spent pre-screening the patient before the visit, checking for symptoms, applying/removing PPE, performing additional cleaning of the examination room, treatment room, tables, equipment. Cleaning supplies, hand sanitizer, disinfecting wipes, sprays and cleansers were used.”

At this time there is no Medicare fee schedule amount for this code, therefore set a fee that you can correlate the charge to the actual additional expenses that your practice has incurred in a reasonable way. Contact health plans to verify coverage prior to billing. Out-of-network providers should be able to charge patients directly. In-network providers may not be able to charge patients for this code — here again, check with the carriers prior to billing.


Telehealth is the use of an interactive audio and video telecommunications system that permits real-time communication between a provider and a patient. Telehealth technology enables the remote diagnosis and evaluation of patients in addition to the ability to remote detection of fluctuations in the condition of the patient so that the specific therapy can be altered accordingly.

The Wall Street Journal stated that telehealth services, which have been around for decades, are getting a boost with patients avoiding in-person doctor visits because of the coronavirus pandemic. Many practices, from small offices to large health systems, are now using telehealth and quickly scaling up their services to meet the demand. Since the start of the public health emergency, the use of telehealth services has increased by 50% nationwide, according to research by Frost and Sullivan consultants, and virtual interactions could reach nearly one billion by the end of this year, according to some analysts.

Before you provide telehealth, contact your state board to see if it is within your scope of practice. Patients should have a prior established relationship with you, however during the COVID-19 public health emergency it could be a new patient. Clinical decision-making or time can be used as the key components in choosing the proper telehealth E/M visit to report. Clinical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option which is determined by considering the amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed.

The number of diagnoses and/or the number of management options must be considered. And the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

nalyze data: CPV, PVA, PCA

What is your Cost Per Visit (CPV)? This amount is calculated by dividing your monthly overhead expenses (e.g., rent, payroll, equipment leases, malpractice, taxes) by the number of adjustments per month. Example: If your monthly overhead is $10,000 and you see 400 adjustments/month (100/week), then your CPV is $25.

Next is Patient Visit Average (PVA). This amount is calculated by dividing the number of adjustments per month by the amount of new patients per month. Example: If you see 600 adjustments/month (150/week) and 20 new patients per month, then your PVA is 30.

Next is Patient Case Average (PCA). This amount is calculated by dividing the amount of revenue per month by the amount of new patients per month. Example: If your monthly revenue is $50,000 and you see 20 new patients per month, then your PCA is $2,500.

Another data exercise is to figure out how much reimbursement you’re receiving per visit per health plan. Here’s how to do it:

Pull the last 25 patients that have come in with Health Plan A for chiropractic careCalculate how many total visits all of these 25 patients receivedCalculate the total amount of money collected for all 25 patientsDivide the total amount collected by the number of total visits to get the amount collected per visitExample: 25 patients received a total of 100 visits. The total amount collected for all 100 visits is $3,000. Then $3,000 divided by 100 visits = $30 collected per visit.

Analyze these numbers with a practice management consultant and see where you stand amongst your peers.

Explanation of benefits

Analyze your insurance explanation of benefits (EOBs). There are five “amounts” that appear on EOBs. They are the charged amount, allowed amount, write-off amount, patient responsible amount and the amount paid to the provider.

Billing managers should meet with the business owner 3-4 times per year and do a concentrated dive into these amounts to ensure that they are being processed properly. We have noticed providers leaving a lot of money “on the table” when this isn’t made a priority or doesn’t get analyzed properly.

Office billing managers have probably heard of CPT code bundling. This is a process that many insurance companies use to deny claims based on the Correct Coding Initiative Edits (CCI edits). A classic example is CMT (9894X) and Manual Therapy (97140). If both of these procedures are performed in the same anatomic site, the CCI edits kick in and “bundle” the codes and only reimburse for 9894X.

ICD-10 bundling is another process that health plans may use to deny claims based on the two types of “excludes notes” within the official ICD-10 guidelines. Each of these excludes notes have different definitions for use but they are both similar in that they indicate that codes excluded from each other are independent of each other.

Excludes 1 is used when two conditions cannot occur together. An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above in the Excludes 1 note. Example: M54.5 (low back pain) has an Excludes 1 indicator with M54.41 (sciatica with low back pain, right side). Therefore, do not report both codes. If both codes are submitted a denial will probably occur. Other examples include M62.- (muscle disorders) with M79.1- (myalgia), and M79.2 (neuritis) has an Excludes 1 indicator with M79.7 (fibromyalgia).

Excludes 2 indicates that the condition excluded is not part of the condition and a patient may have both conditions at the same time. When an Excludes 2 note appears under a code it is acceptable to use both the code and the excluded code together.

Fee schedules and authorization

There are pros and cons to being an “in-network” provider. One of the benefits is the ability to analyze the participating provider reimbursable amounts per code.

Some providers are in-network with many plans and if precise tracking of payable amounts does not occur, it will stall the growth of a practice. One of the negatives of being in-network with multiple plans is that it’s hard to track and this causes frustration in the billing department. Some offices get “stuck” billing for limited procedures because they didn’t know other services were available for coverage or only bill for passive modalities (e.g., hot pack, e-stim). They do not do a deep dive into the fee schedules and do not realize all the services that may be authorized within the plan.

Also make sure to be collecting the proper co-pay amounts. If you do not collect the proper amounts and the patient does not return for care, you then may have to “chase” after the patient by sending statements in the mail. It’s important to get patients to understand their financial responsibility.

Analyze the data and track how much should be paid per visit while the patient is actively being treated. While some offices may find it easier to simply mail patient statements, there are usually hidden costs associated with this. It may cost between $5-$10 per patient to send and process each statement by mail, plus once you mail a statement you are decreasing your chances of receiving payment. Studies show that the chance of collecting from a patient drops almost 20% as soon as the patient becomes inactive. Do your best to track and analyze your fee schedules. Start with a simple Excel spreadsheet and enter the name of the plan and the payable amounts per service provided along with the deductible and co-pay amounts per group plan.

Fighting back

After analyzing data, you may come to the realization that some plans are not paying your claims properly and in accordance with the fee schedule. And no matter how much you appeal, they cannot give you a straight answer or be logical with their reason for the aberration in payable amounts. This can be very frustrating.

Here are a few steps to consider:

Demand to speak to a supervisor and show them how the claims are being processed incorrectly — they must take action and try to help you, especially because you’re a participating provider.Get patients involved, especially because it may cause a financial burden on them. They can call and demand an answer to this situation. Health plans are more likely to take action when patients complain versus the health care provider.Contact your state chiropractic association and make them aware of this. Hopefully your state association dues include an attorney to speak to about this situation.You may be able to file a formal complaint with your state insurance commissioner.Contact your own attorney and send a letter to the health plan demanding a resolution.Contact the American Chiropractic Association or the International Chiropractors Association and make them aware of this.

Also, I recommend that you hold on to the pre- and post-EOBs that show unusual payment patterns — this could be used to re-submit claims for proper reimbursement.

Fee confusion and resolution

All patients should be aware of your normal fees, especially if you are providing discounts. Some give discounts without advising patients of the practice’s normal fees and this can cause “sticker shock.” Patient education is important now more than ever. Address medically necessary and wellness care during the report of findings. In my opinion, all patients can be categorized into either active care or wellness/maintenance care. During active care or active treatment the patient has pain, restricted motion, inability to perform normal daily activities, muscle spasm, sprains/strains and decreased functional performance. Active care/active treatment is typically covered by health insurance because it is considered “medically necessary.”

On the other hand, during wellness care, the patient has very little or no pain, has good motion and can perform most/all normal daily activities. Once a patient has plateaued or reached maximum therapeutic improvement, this is considered maintenance care. Wellness and maintenance care is not typically covered by health insurance because it is considered “not medically necessary.” Make sure the patient has a clear understating of the difference and you will see improved reimbursement.

MARTY KOTLAR, DC, CPCO, CBCS, is the president of Target Coding. Over the last 12 years he has helped hundreds of chiropractors and integrated practices with compliance as it relates to billing, coding, documentation, Medicare and HIPAA. He is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals and a guest speaker at many state association conventions. He can be reached at 800-270-7044,, or at

The post New coding that removes roadblocks to health care reimbursement appeared first on Chiropractic Economics.


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