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New CMT Codes — 98940, 98941, 98942  (January 1997)

The hoopla of the new year is over along with the hoopla of the new CPT codes for chiropractic. After the party dies down, the implications of these codes will stay with us. The question is: will they be a monster hangover? From one perspective, it is wonderful to not have to use codes designed for physical therapy or osteopathy. As a profession, we have codes designed to describe our procedures. The operative question is this: what did we lose in the process? Let’s first look at the definitions of the codes themselves.

As of January 1, 1997, new procedure codes for adjustments (manipulations) will take effect. These codes, patterned after the osteopathic manipulation codes released in 1996, break the spine down into five distinct regions. For purposes of CMT, the five spinal regions referred to are:

1. cervical region (includes atlanto-occipital joint)

2. thoracic region (includes costovertebral and costotransverse joints)

3. lumbar region

4. sacral region

5. pelvic region (includes sacroiliac joint)

The CMT code you choose depends on the number of regions adjusted by the doctor. Notice, the code reads regions not vertebrae. Even if the doctor adjusts C1, C2 and C7, only one region — cervical — has been adjusted. The codes are as follows:

98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions

98941 spinal, three to four regions

98942 spinal, five regions

98943 CMT, extraspinal, one or more regions

There are also five extraspinal regions:

1. head (including temporomandibular joint)

2. lower extremities

3. upper extremities

4. rib cage

5. abdomen

Determining which code to use: If the doctor adjusts only upper cervical, the appropriate code would be 98940. When the doctor adjusts full spine (cervical, thoracic and lumbar), you could use 98941. For doctors who usually adjust full spine, this code could be the most frequently used; from a pessimistic viewpoint, though, your documentation requirements will undoubtedly be much stiffer since you must document the need to adjust full spine. There’s not much doubt that the RVS (Relative Value Scale) will be higher for 98941 than 98940. (This means you will get paid more.) On the other hand, 98942 (five regions) will probably be used sparingly. In my opinion, 98942 will need extensive documentation. In addition to the codes for spinal manipulation, 98943 represents extremity or rib adjustments. You might encounter situations such as carpal tunnel syndrome where the neck is adjusted along with the wrist or elbow. It would be appropriate to use both 98940 and 98943. Likewise, if a patient is experiencing jaw (TMJ) problems, you might manipulate the neck and the TMJ. Using both codes adequately describes your treatment. One word of caution: make sure that the scope of practice law for your state allows extremity adjusting before you use 98943. There are some states (Michigan, for example) where the scope of practice law limits manipulation to the spine.

Using CMT codes and E/M codes on the same visit

The chiropractic manipulative treatment codes include a pre-manipulation and postservice patient assessment. According to CPT 1997, "additional Evaluation and Management services may be reported separately using the modifier-25, if and only if the patient’s condition requires a significant separately identifiable E/M service, and above and beyond the usual preservice and postservice work associated with the procedure." How do you interpret that statement? Here’s my interpretation: if you perform an extensive new patient exam and adjust the patient on the first visit, you could use 99202-25 or 99203-25 in addition to the CMT code. Likewise, if the patient experiences an exacerbation, a new injury or different symptoms, you could justify the E/M code along with the CMT code. Otherwise, the CMT code includes the pre- and post-adjustment exams such as palpation and leg checks that the doctor performs on an ongoing basis.

Medicare and CMT Codes

Medicare in most states has already indicated that the new codes will replace A2000 with a three-month grace period where A2000 will still be honored along with the new codes. Let’s look at Medicare law for clues to interpretation of the CMT codes. "Payment of chiropractic services is limited to manual manipulation of the spine for the purpose of correcting a subluxation demonstrated by x-ray." Since Medicare will pay only for manipulation of the spine, 98943 would not be reimbursed even if its use falls within the scope of practice law. Second, if you intend to use 98941 or 98942, you are almost required to shoot full spine x-rays since Medicare requires that subluxations be demonstrated by x-ray. That's my interpretation.

While 98941 will certainly be reimbursed at a higher relative value, there will also be added requirements.

So, are the new CMT Codes a blessing or a curse?

Everyone has their opinion of the new codes, so here’s my opinion:

98940 — if the RVS for this code matched the osteopathic manipulation codes, I’d applaud. Right now, I think the applause would serve no purpose since we obviously don’t need the air conditioning caused by flapping arms.

Unfortunately, it seems that the osteopathic codes will be reimbursed at a higher rate than the comparable chiropractic codes so the disparity will continue. Because the higher level codes (98941 and 98942) will be reimbursed at a higher level, my fear is that many chiropractors may use the higher codes when they are actually performing the service described by 98940. I don’t want to see anyone jeopardize his/her reputation for the sake of higher reimbursement.

98941 — I think many chiropractors will try to use this code and encounter documentation problems in its use. Remember, it can only be used if the doctor adjusts three or four regions of the spine. In my interpretation, you would need a diagnosis and correseponding progress notes for each area; you would need supporting documentation in terms of subjective or objective findings. Those offices who use this code with high frequency may be painting a bullseye on their backs and asking for an audit. I see one other problem wth 98941. If you diagnose three or four regions of the spine, they all become pre-existing conditions. When the patient experiences a new injury or exacerbation, it occurs in an area which was already under treatment. Rather than being a new condition, it becomes a continuation of an underlying problem. It is unlikely that an insurance company will buy into the scenario where there is a new injury or exacerbation every three months for the sole purpose of justifying ongoing care.

It’s your call

Probably the biggest blessing of the CMT codes is their specificity. We have codes designated for chiropractic and no longer have to use 97260 which is a physical therapy code or 98920 which is osteopathic manipulation. With the inherent limitations and implications, you decide — is that a blessing? As I write this article, I’m not sure!

Contributed by:  Marilyn Gard, President, Clinic Pro Chiropractic Software, marilyn@clinicpro.com

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To meet Medicare guidelines for mechanism of trauma, ClinicPro chiropractic software has developed an EMR template that elicits the mechanism of trauma information along with PART information meaning pain, asymmetry, range of motion and tissues/tone changes. This chiropractic specific documentation justifies the use of procedure codes 98940 and 98941. Medicare chiropractic guidelines require a mechanism of trauma to initiate care. ClinicPro chiropractic software provides a documentation necessary to pass a Medicare chiropractic audit.
To meet Medicare guidelines for mechanism of trauma, ClinicPro chiropractic software has developed an EMR template that elicits the mechanism of trauma information along with PART information meaning pain, asymmetry, range of motion and tissues/tone changes. This chiropractic specific documentation justifies the use of procedure codes 98940 and 98941. Medicare chiropractic guidelines require a mechanism of trauma to initiate care. ClinicPro chiropractic software provides a documentation necessary to pass a Medicare chiropractic audit.
 To meet Medicare guidelines for mechanism of trauma, ClinicPro chiropractic software has developed an EMR template that elicits the mechanism of trauma information along with PART information meaning pain, asymmetry, range of motion and tissues/tone changes. This chiropractic specific documentation justifies the use of procedure codes 98940 and 98941. Medicare chiropractic guidelines require a mechanism of trauma to initiate care. ClinicPro chiropractic software provides a documentation necessary to pass a Medicare chiropractic audit.