BCBSIL E/M Claim Appeal Template Language

BCBSIL E/M Claim Appeal Template Language

As we reported a few months ago, at the Illinois Chiropractic Society’s prompting, the American Medical Association (AMA) revised a previously issued CPT® Assistant article from 2007 related to billing for exams on the same day as a chiropractic manipulative treatment (CMT). The AMA considers the CPT® Assistant to be “the official newsletter that educates the industry on proper CPT coding.” In short, it gives guidance to the CPT® guidelines when further explanation is warranted. Although there are varying opinions as to the extent of the CPT® Assistant’s legal authority, some insurers use its articles to make decisions about coverage and claims processing.

Chiropractic physicians across Illinois have received and continue to receive denials from BlueCross Blue Shield of Illinois (BCBSIL) when billing an Evaluation and Management (E/M) service with a -25 modifier for a proper examination on the same date as performing a CMT. Following an appeal, in many cases, BCBSIL would continue to deny the billings, citing a CPT® Assistant article from 2007. Unfortunately, the previous CPT® Assistant article had included in the CMT an extremely wide variety of evaluation services, including “evaluating any new complaints.” As a result of ICS action on your behalf, the new CPT® Assistant article has removed that broad “new complaints” language.

We believe this will assist our doctors with their appeals and other potential future actions. Although the ICS was not permitted to be involved in the actual drafting, review, or approval of the new language, we believe our calling attention to the prior reference to “evaluating any new complaints” resulted in its removal and represents a significant improvement that will help our doctors appeal improperly denied claims. The AMA has granted permission to the ICS to release the new CPT® Assistant article to our members, and you can find it here.

Furthermore, in 2018 BCBSIL issued a new “Clinical Payment and Coding Policy” in 2018 for chiropractic services that refers to examinations:

Billing an Evaluation and Management (E/M) Code with a CMT code: In general, it is inappropriate to bill an established office/outpatient E/M CPT® code (99211-99215) on the same visit as Chiropractic Manipulative Treatment (CPT ® code 98940-98943) because CMT codes already include a brief pre-manipulation assessment. There are times when it would be appropriate, but it should not be routine. Examples of when it may be appropriate to bill an additional E/M service would be the evaluation of new patients, new injuries, exacerbations, or periodic re-evaluations. (https://www.bcbsil.com/pdf/standards/chiropractic_services.pdf)

As a result of these two major changes, we are encouraging chiropractic physicians to appeal and include references to these important documents. In addition to your typical medically necessary appeals for -25 modifier denials, the ICS would recommend including both of the following when appealing:

  1. Chiropractic physicians should utilize the new BCBSIL payment policy, citing the E/M language when appropriate. If you are billing for a CMT on the same date as an E/M that was documented and performed for a) a new patient, b) a new injury, 3) an exacerbation, or 4) a periodic re-evaluation (periodic re-evaluations should follow the standard of care for the condition being treated); your appeal should include a reference to this BCBSIL “Clinical Payment and Coding Policy” – PCP016 – Version 6.0.

We would also recommend that you include a link to the policy (provided above), indicating the page number (page 7), and which specific exception applied to the E/M denial that you are appealing.

This portion of the appeal could read:

“According to the BlueCross BlueShield of Illinois Clinical Payment and Coding Policy – PCP016 – Version 6.0 for chiropractic services, the evaluation and management (E/M) services provided on the same date as the chiropractic manipulative treatment are appropriate. The E/M service in question was performed for [include one of the following: a new patient, a new injury, an exacerbation, or a periodic re-evaluation necessary to meet the standard of care]. Please see paragraph on page _ of the included documentation which clearly indicates the purpose of the examination.”

Of course, this is in addition to any medical necessity verbiage which should be included in the appeal.

2. If the exam is for a new condition, then in addition to the BCBSIL policy, chiropractic physicians should reference the new, updated CPT® Assistant article issued November 2018, page 12. Please review this new CPT Assistant language to ensure you have met all the requirements. You can indicate in your appeal that the AMA’s new CPT® Assistant language no longer indicates that evaluating new complaints is a part of the CMT. That would be a clear separate and distinct service meeting the CPT codebook definition for a -25 modifier.

This portion of the appeal could read:

“The CPT® Assistant article issued November 2018, page 12 specifically does NOT include evaluating new complaints as a part of the chiropractic manipulative technique. This E/M service was clearly separate and distinct from the other services performed on the same day. Please see paragraph _ on page _ of the included documentation which clearly indicates the purpose of the examination was for a new complaint by the patient.”

The Illinois Chiropractic Society is continuing to work for our doctors on this ongoing problem. Additionally, our outside legal counsel is continuing to investigate legal action regarding BlueCross BlueShield of Illinois’ claim processing protocol. As more information develops, we will inform our members.

About Author

Marc Abla, CAE

Marc Abla began working at the Illinois Chiropractic Society in 2002 and became the Executive Director in 2008. He brings his extensive financial, administrative and association experience to the ICS. He is a Certified Association Executive and a graduate of the Certified Leadership Series through the Illinois Society of Association Executives. Additionally, he is a member of the Illinois Society of Association Executives, the American Society of Association Executives, Association Forum, Congress of Chiropractic State Associations, and the American Chiropractic Association.


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