BCBSIL Releases “Chiropractic Services” Policy
The Illinois Chiropractic Society is continuing to work with various entities and attorneys regarding the ongoing BCBSIL claims edit process modifier problem that most of our doctors are facing. We understand the burden that our doctors are enduring, and it remains our top priority.
Recently, BCBSIL released Policy Number: CPC016 Version 6.0 in their Clinical Payment and Coding Policies section, and according to the “Policy Update History,” this is a new policy. You can find the policy here: https://www.bcbsil.com/pdf/standards/chiropractic_services.pdf
The Illinois Chiropractic Society is working with many professional experts who are independently reviewing the entire document. Once we receive those various expert opinions, the ICS will respond to BCBSIL with any concerns and requested changes.
Important Policy Provision
For doctors whose claims are persistently denied for E&M and CMT billed on the same visit (i.e., 25 modifier denials), you will find an important provision in the policy. On Page 7, under Coding Reminders, BCBSIL indicates “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.” [emphasis added] This language appears to differ from BCBSIL’s previously stated reason it has given in denials of a claim inquiry or appeal based on an unpaid E & M fee on the same date as a CMT.
The ICS believes it is appropriate to bill and receive payment for an additional E/M service under the circumstances described in the highlighted portion of the BCBSIL policy above. Therefore, when doctors are appealing claims edit denials for -25 modifier claims, the ICS would encourage doctors to cite BCBSIL’s Policy Number: CPC016, Page 7 with the specific language mentioned (if applicable). It is too early to determine if this approach will be successful, but we believe it will improve our overall position as we continue to seek a resolution to the claims edit problem.
The ICS will continue to update chiropractic physicians regarding the claims edit process and this new policy in the coming weeks and months.