Medical billing is an essential component of the healthcare industry. If you own a practice for chiropractic services, you will also need to ensure accurate medical billing and coding for the fair and timely reimbursement of your services.
However, healthcare providers often try to avoid medical billing and claim submissions due to their complex nature. But it is not complex anymore! At MediBillMD, we have identified coding as the core of medical billing challenges.
That’s why we will discuss CPT code 98940 in detail, and explain its practical uses, applicable modifiers, and guidelines for proper reimbursements. So let’s start with the official description of the code.
CPT Code 98940 Description
CPT code 98940 refers to a chiropractic service where the provider uses manipulation to influence joint and neurophysiological function in one to two spinal regions. The chiropractic manipulative treatment (CMT) involves manual correction using hands or specialized instruments to apply controlled force to the joints.
The targeted spinal regions usually include:
- Cervical region (includes atlantooccipital joint)
- Thoracic region (includes costovertebral and costotransverse joints)
- Lumbar region
- Sacral region
- Pelvic region (sacroiliac joint)
However, it is important to remember that the number of spinal areas treated in a single session determines the appropriate code. For example, if the provider is treating more than two and less than five regions, then instead of using CPT code 98940, the provider will use CPT code 98941.
Scenarios Where CPT Code 98940 is Applicable
To support this description with valid examples, you can read the following scenarios that exclusively explain the correct uses of CPT code 98940.
Chronic Cervical Pain
Suppose a 35-year-old woman slept in the wrong position at night. She wakes up with severe neck stiffness and a shooting pain traveling from her neck to her shoulders and arms. The healthcare provider finds out that a cervical subluxation occurred due to a bad sleeping posture.
Therefore, he performed CMT on one spinal region only – cervical. In this case, the provider can charge for his services using CPT code 98940 because he treated one spinal region.
Thoracic Spine Discomfort
Consider a young woman in her 20s who goes to a chiropractor complaining of tightness between her shoulder and persistent upper back pain. She usually faces this issue after spending hours sitting on her bed, crouched over her phone, and scrolling through reels.
The chiropractor examines the patient and finds a vertebral subluxation complex (VSC). He merely applies a targeted chiropractic manipulative treatment (CMT) to the thoracic spine. The proper billing code for this service is CPT code 98940 because the treatment is restricted to a single spinal area.
Lumbar Subluxation
Suppose a 35-year-old man who works out regularly and often lifts heavy weights visits the chiropractic practice with acute lower back pain after a heavy lifting session. During the chiropractic assessment, the provider observes muscle tightness and a mild misalignment in the lumbar region.
However, no other regions of the spine show signs of misalignment. The chiropractor diagnoses a lumbar subluxation resulting from mechanical strain and performs spinal manipulation exclusively in the lumbar region to alleviate pressure and restore alignment. Since only one spinal region is treated, this visit is accurately billed under CPT code 98940.
Applicable Modifiers for CPT Code 98940
Modifiers are used to communicate additional information about the services rendered to the patients. You can append the following modifiers to CPT code 98940.
Modifier 59
Modifier 59 is used for services that are distinct from the primary service. Suppose you are providing a massage therapy along with manual manipulation of a spinal region, you can append this modifier with CPT code 98940 to indicate to the insurance payer that both services were distinct. However, modifier 59 is a general modifier and is often used by various service providers. So, it is advised that you use the subsets of modifier 59 (XE, XS, XP, and XU) to be more specific and explain how the two services were distinct.
Modifier AT
It is essential to apply modifier AT with active chiropractic services. Otherwise, the claim will be rejected. This modifier indicates that services rendered to the patient were part of corrective treatment and meant to improve the patient’s health instead of maintenance care. If you file CPT code 98940 without the AT modifier, Medicare will reject the claim because maintenance therapies are not covered.
CPT Code 98940 – Billing & Reimbursement Guidelines
Every code has its own particular reimbursement and documentation requirements. So does CPT code 98940! Let’s read its specific guidelines for more clarity and prevent potential claim denials.
Documentation Requirements
Complete and accurate documentation is the basis of every claim. If there is an error in your documents, it will trigger a denial. So, to avoid denials, the first thing you must do is maintain accurate and thorough documentation for chiropractic manipulative treatment of one or two spinal regions (CPT code 98940).
These documents should include every detail about the service and must support the medical necessity of the treatment through ICD-10 diagnostic codes. It can take a lot of effort, but providers must include the patient’s medical history, evaluation, treatment plan, and progress notes. However, the following information must also be included in the paperwork.
- Date when the treatment course was initiated
- Primary diagnosis codes
- Secondary diagnosis codes
- Date of service
- Place of service
- Spinal regions manipulated
- Manipulation tools and techniques used
- Treatment outcomes
Failure to report these details may result in claim delays or denials.
Accurate Modifier
Applying the correct modifier (when needed) is another best practice in medical billing. As mentioned above, providers must apply modifier AT with CPT code 98940. Otherwise, claims without the AT modifier will be considered maintenance services and will be denied due to non-coverage, affecting your practice’s revenue.
Frequency of Services
Medicare and other insurance payers often limit the number of chiropractic services in a year. This ensures appropriate utilization of chiropractic services and helps manage costs, according to the Centers for Medicare & Medicaid Services (CMS).
Currently, the CMS’s local coverage determination (LCD) maintains a limit of 25 visits per rolling year when billed with modifier AT. This means that when filing for CPT code 98940, it is important to ensure that your patient is not exceeding the limit.
Payer Policies
When filing claims, it is important to keep an eye on payers’ policies. You must familiarize yourself with how various payers reimburse and accept specific codes. For example, Medicare does not accept CPT code 98940 without an AT modifier. They assume that services were given for routine maintenance purposes and eventually deny the claim. To avoid these denials, you must stay aware of payer requirements, coverage changes, and any new rules related to chiropractic billing.
Summary
To summarize this blog, CPT code 98940 represents chiropractic services where the provider manually manipulates 1 to 2 spinal regions. This code is usually applied for minor subluxations in the spine. However, it is necessary to append the modifier AT to this code. Otherwise, you will receive a denial. Furthermore, the specific coding guidelines outline the frequency of the service per year.
However, if you are still unclear about this code, we would highly suggest acquiring chiropractic billing services from experts who possess in-depth knowledge of coding and insurance policies. It will ensure accurate submissions and minimize claim denials, improving your cash flow.
