Key Provisions in 3rd Party Payer Policies
All insurance companies have rules or policies that outline information about the services for which they pay. This week we provide information on some of the key provisions outlined in 3rd Party Payer policies.
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Transcript:
All insurance companies have medical policies, your policies that give the rules, if you will, or outline information regarding the services for which they pay. An example would be specific to chiropractic for us, right? United Healthcare, their’s specifically deals with a service, not all services, but some services, and their policies center around mostly manipulative therapy policies. Now, Blue Cross Blue Shield, on the other hand, kind of does a larger grouping for the chiropractic profession as a whole, and the title of their policy regarding those services are the most services that we render our chiropractic care services.
If you have not reviewed that document, we strongly urge you, they began to produce a document from Blue Cross Blue Shield anyway, about 2018. They update it on a fairly regular basis. For example, when the time therapy code changes took place a few years ago, they made changes to the document then, and then of course, at the beginning of 2021 when E and M code changes occurred, they updated the document again there, but they do annual updates to the document as well. I wanted to go over a couple of key items, things you want to be aware of, we’re going to cover these over the course of a handful of weeks, because we want you to be aware. Now just because these are policies within Blue Cross Blue Shield doesn’t mean that they only apply to Blue Cross Blue Shield. In some cases, these are going to be good things to implement in your practice across the board. But we always encourage you to look at all of the policies surrounding the services you offer in your practice for each one of your insurance companies.
So what are the key things that are covered in some of these policies? Well, it could be documentation standards, coding standards, diagnosis codes, information about specific services, or coding reminders, in fact, in the Blue Cross Blue Shield one they even include some DME and imaging information as well, some important key pieces of information that you need to be aware of. So let’s talk specifically about some things that they call out in regards to the documentation standards, and coding information surrounding the CMT codes or the 98940, 98941, 98942, and 98943 codes. So all of the spinal codes as well as the extra spinal manipulation code, with 98943. Here are the things that they lay out that they indicate are critical.
Let’s talk first and foremost about your claim form on the 1500 claim form, you have to make sure that you include a diagnosis code that incorporates all of the regions for which you’re billing. So for example, your billing a 98940, and only requires one, so you have to make sure that you have a minimum of one spinal-related diagnosis code. And if you have a 98943, you want to make sure that you have a minimum of one extra spinal or additional joint manipulation or a joint region, if you will, that you are adjusting with a 98943. However, when we get to the 98941, and two, those obviously are additional regions. So for 98941, there has to be a minimum of diagnosis codes that cover a minimum of three regions. So the way that they state that specifically is you must have an ICD 10 code for 98941 specifically, as the example that they give, you must have an ICD 10 CM code that incorporates at least three different regions. By the way on 98942, then you would have to have five different regions covered with your diagnosis codes, that’s going to be really important, especially with the recent includes one changes that they implemented, and if you’ve seen di, if you’ve seen some denials, coming from Blue Cross Blue Shield that are related to your diagnosis code, make sure that you check out our article that previously we published we’ll include a link in this description to that article, specifically in regards to the excludes ones. But again, it’s really important on your claim form, make sure that you cover all of the regions that you’re adjusting in the diagnosis codes.
Now, what what must the documentation include, for CMT codes? Well, one is you have to have the location that seems rather obvious, and I’m sure that all of you are doing that. You have to have specific regions that you adjusted, of course, no doubt. But also you have to include the technique that you use, that is actually a requirement laid out inside their medical policy is not just the reason that you adjusted, but also the technique that you used for the adjustment. One thing that we always talk about is outcomes assessments, right? So another item that you have to include in your documentation is the response. So what’s the patient’s response to the treatment? The adjustment including whether or not the pain or condition being treated increase, reduced, or eliminated the problem. So that is going to be another key component.
Now last is really interesting and this is what they indicate that each manipulation reported. Each CMT reported must be related to the patient’s complaints, and a relevant symptomatic spinal or extra spinal level. So that’s another key one. Key takeaways for today, make sure that you have diagnosis codes that clearly reflect all of the reasons that you’re adjusting. It’s very critically important. Make sure that your documentation includes the technique use the patient’s response, and that it’s all specifically related to a patient complaint, actually the way the patient complaint and relevant symptomatic spinal arch or spinal level. So hopefully, this information helps you out we’ll include a link to Blue Cross Blue Shield’s policy and a policy for UnitedHealthcare inside of this video description. Catch you next week.
