r. X has been in practice for more than 25 years. As a beloved and trusted practitioner in his town, his patient database bulges with past and present patients. Because the office is in a rural community, patients include farmers and ranchers, retirees, and some families. They were used to coming in for care when it was needed, and didn’t much believe in that “maintenance care”. Imagine his surprise when the audit letter came in from Aetna Insurance, asking for 10 of his patient files. He dutifully copied all the records, sent them in, and felt pretty good about the potential outcome, since he felt he was a “pretty good documenter”. The next correspondence from Aetna nearly knocked him off his chair.
Dr. X had a set protocol he followed on everyone. Along with chiropractic manipulations, patients received ice and electric muscle stimulation during the first few weeks of care, and then heat and muscle stimulation for the rest of the treatment episode. Sometimes, these episodes went on for as many as 6 months. No active care or other services were rendered in the office. Dr. X confided to me that he always felt a practice like this just flew under the radar, since surely his care was not the problem of insurance gouging. He quickly learned that the third-party world saw things differently than he did.
Aetna asked for nearly $35,000 back. Surely this could not be the result of review of only these 10 charts! Aetna used a procedure called “extrapolation” where the actual discrepancies were calculated, and the multiplied across the entire classification of Aetna insureds that had been paid to this doctor over the prior three years. Here was the breakdown:
- $13,500 in 97010 (hot and/or cold packs) billing that was deemed “not medically necessary”
- $12,500 in 97014 (electric muscle stimulation) that was deemed “not medically necessary”
- $4,000 in 99213 (established patient evaluation and management) that was denied as an unbundled service
The Protocols Failed the Doctor
97010, hot/cold packs, is often a necessary service. In fact, it is the position of the American Chiropractic Association that “the work of hot/cold packs as described by CPT code 97010 is not included in the CMT codes 98940-43 in instances when moist heat or cryotherapy is medically necessary in order to achieve a specific physiological effect that is thought to be beneficial to the patient. Indications for the application of moist heat include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation, and increase in lymph flow to the area. Indications for the application of cryotherapy include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation, and increase of lymph flow to the area.” The doctor believed that these reasons were why the patient was receiving these services, but the documentation didn’t continue to show the medical necessity for ongoing ice/heat in the office, along with the manipulations. Nothing in the patient’s record indicated on a daily basis that the ice/heat was being used for any of these things. Dr. X thought that explaining this once in the beginning of care, in the treatment plan, was enough. The same problems existed with the electric muscle stimulation, and the documentation deficits were similar. He had no choice but to reimburse the carrier for these amounts and try to do better going forward.
How Do We Improve This Situation?
Medicare made the decision in 1996 that 97010 would be considered a “bundled” service for all provider types and not reimbursable. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. In this instance it means code 97010 is not a separately billable service when rendered to a Medicare patient. It is considered a part of whatever primary service is rendered to the patient; either CMT code 98940, 98941, or 98942. This is different than a "non-covered" service, which can be charged to the patient. A bundled service cannot be charged to the patient, as it is being reimbursed within another code’s value. Many private and commercial carriers have taken on the same policies and definitions of medical necessity. Therefore, it’s important that you set a protocol for 97010 usage in your office that meets the guidelines for the carriers you’re working with, and where efficacy of the outcomes of 97010 can easily be documented in your patient’s record.
Try these procedures and protocols to help justify your prescription for ice/heat in the office for your patients:
- Clearly document the physiological effect you expect to gain from the 97010 service, whether heat or ice, in your treatment goals. Goals are not just for your adjustments. Goals are for every service you order for the patient.
- Be realistic about the length of time into the episode of care that you will continue to render this heat/ice service in the office. Unfortunately, the evidence based practice of heat and cold modalities is limited and the knowledge is purely empirical. This knowledge dictates that ice therapy is used during an acute phase of treatment. If you are using ice beyond this phase, clearly document the reasons why. Likewise, heat therapy has excellent uses as the patient is returning to normal function, and preparing for active care in the office. Be reasonable about what levels of this care must be performed in the office and what can be transferred to home care, after careful training and explanation.
- During the active use of heat/cold therapy during the episode of care, continue to comment in your daily treatment notes about the continued efficacy of the modalities you’re using. Remember to comment in this way: “The patient is improving and I know this because…” and “The patient needs more care (hot/cold) and I know this because…”. This will assist you with the practical explanations of the necessity of this care.
As a clinician, only you know what the patient really needs. You are the custodian of those health care dollars because you indicate the medical necessity of the care with your signature on the billing form. Don’t get stuck in outdated practices and protocols that haven’t been updated in years. The use of treatment protocols is excellent, and they can be a tremendous tool in your treatment planning and execution. Just be sure that the protocols you’re using are easily discernible and defendable should you wind up on the wrong end of a $35,000 recoupment letter.
Kathy Mills Chang is a Certified Medical Compliance Specialist(MCS-P), and since 1983 she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at (855) TEAM KMC or