Q:  I have a payor who is denying modalities, claiming that they are “excessive”.  At a single encounter I billed for:

  • 98940Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
  • 97110Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
  • G0283Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
  • 97010Application of a modality to 1 or more areas; hot or cold packs

Is this excessive?  How do I know how much is too much?

A:  First it is important to point out that modalities can be considered passive or active.  Some folks consider therapeutic procedures, like 97110, to be active modalities.  Others might say that modalities do not include therapeutic procedures, but that they are in their own category.  Regardless, many payors get worked up over too many of the same type of passive modality at the same visit.  For example: infrared, hot packs, and diathermy all at once.  That might result in a little overcooking.  But they tend to get more worked up over doing passive modalities like 97010 for 30 visits when 6-12 may be more appropriate.   

Here is a reference from a private payer that sums up the opinion of many reviewers:

  • The provider should attempt to integrate some form of active care. Continued use of passive care modalities may lead to patient dependency and should be avoided.
  • The utilization of more than 2–3 passive modalities per office visit is excessive and is not supported as necessary.
  • These rules hold true for acute, chronic and postsurgical cases. No matter what specific treatment is chosen, it must yield identifiable, objective outcomes to establish the necessity of care.

Passive modalities are most effective during the acute phase of treatment, as they are typically directed at reducing pain and swelling. They may also be used during the acute phase of an exacerbation of a chronic condition. The optimal duration of a course of passive modalities is a maximum of one to two months, after which their effectiveness diminishes, and patient dependency may develop.

Treatment plans for patients who are at risk for developing chronic conditions should de-emphasize passive care and refocus on active care approaches. When utilizing passive modalities after a lasting physiological benefit has been reached, the modalities serve only to facilitate the manipulation and are considered integral to the manipulative procedure.

Most uncomplicated cases can be adequately managed with spinal manipulation plus one or two adjunct modalities. Using more than two to three adjunctive passive modalities in one visit, in addition to joint manipulation, is considered excessive and not of proven benefit.

-Cigna Coverage Policy 0267 (emphasis added)

There are many helpful points in this policy, but it appears that Cigna would have no problem with a couple of passive modalities at a single visit, as outlined in the question above.  You may want to appeal that denial.  However, it would be wise to avoid doing these passive services at the end of care after they should have already provided their benefit early on.  A visit with both active (97110) and passive modalities (97010, G0283) would make the most sense in the middle of a care plan as a patient is transitioning from one stage of care to the next.  

This question was answered by Dr. Evan Gwilliam, Clinical Director for PayDC chiropractic EHR software.  If you are looking for an integrated, compliant, cloud-based solution to all of your scheduling, documentation, and billing challenges, look no further. Contact Dr. G to schedule a demo.  evang@paydc.com