Make the Claim Form Do the Work  Jeremy Haug February 27, 2023
Make the Claim Form Do the Work 

Chiropractors are among the last people who wake up in the morning and get excited about learning about medical coding.  In the healthcare business world, a provider must select a diagnosis code (ICD-10), link it to a procedure code (CPT), and place it on a claim form (CMS-1500) and then submit the information to a payer and hope there are no mistakes.  If successful, then the provider gets paid. 

The claim form is the first line of communication with third parties.  Providers can document all they want and have perfect records, but if the claim doesn’t match, or doesn’t tell the story properly it can lead to all kinds of trouble.  But there are a few simple coding secrets that can change the doctor’s fortunes to make sure these kinds of struggles are avoided.

1.     Diagnosis pointing:  Before payers ever see the provider documentation, they receive the claim form, with its procedure and diagnosis codes.  The claim form allows for twelve diagnoses (labelled A through L), and each procedure that is billed can be linked to four of them.  Take the extra time to make sure that each procedure is not linked to diagnoses that don’t make sense.  For example, 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions should never be linked to spinal diagnosis codes, like M99.01 Segmental and somatic dysfunction of cervical region.  

97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes is bundled if it is done in the same region as CMT.  Therefore, it stands to reason that the CMT code and the manual therapy code would not point to the same diagnoses.   This can be laid out very easily in column E of box 24 on the CMS-1500 form, with each procedure tied to unique diagnoses.  

2.     Let the claim form tell the story about progress:  Over time, patients are expected to improve.  The documentation can show this in the record through the provider assessment.  However, the claim form may be able to convey this information to the payer without them ever having to look at the clinical records by simply dropping diagnosis codes from subsequent encounters.  As the patient receives care, conditions resolve. When they are no longer present, the codes should no longer be reported.

Providers can also report progressively lower-level procedure codes.  For example, a re-exam at four weeks after care began might be billed as 99213, or a level 3 Evaluation and management code for established outpatients.  When the patient is examined four weeks later, there may be so few problems that the exam is more brief, less complicated.  The reported code might be 99212 which indicates less medical decision making took place.  

Similarly, when a patient first presents for care, and claims to have trouble from stem to stern, a 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions might be appropriate.  Then after a few treatments, medical necessity might only be present for three or four regions, and the appropriate code to bill might be 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions.  Towards the end of care, the patient may only meet medical necessity for 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions.  In this way, the claim form can tell the reader that the patient is getting better throughout the course of treatment.  

These are just a few ways a savvy DC can use the claim form to make sure the story of patient progress is told, and therefore medical necessity is reinforced.  If the claim form is used properly, there may be no need to send in notes, saving the doctor time and money.