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Is 98943 mutually eclusive to 98941?

Angie Posted Tue 16th of October, 2012 20:23:40 PM

Recently some of our major med payers have started denying 98943 as mutually exclusive to 98941.According to CMS, these CPT codes are not bundled. Could the issue really lie with not assigning a different diagnosis codes to the 98943? I think so but any input or advice is appreciated!

SuperCoder Answered Tue 16th of October, 2012 20:37:43 PM

It could be the major reason.It would be necessary to report two CPT codes to adequately describe the treatment described. CPT code 98941, Chiropractic manipulative treatment (CMT); spinal, three to four regions, would be reported for the CMT of the three spinal regions (cervical, thoracic and lumbar), and code 98943, Chiropractic manipulative treatment (CMT); extraspinal, one or more regions, would be reported for the CMT of the temporomandibular joint (extraspinal manipulative treatment).

Otherwise these two codes are not mutually exclusive.

In addition, Medicare and most private insurers require a diagnosis of subluxation of the spine to demonstrate medical necessity for CMT billing.

"The precise level of subluxation must be specified through use of the appropriate diagnosis code(s) on the claim," notes a policy from Palmetto GBA, a Part B payer in eight states.

"Secondary diagnoses must be present on the claim to indicate the significant neuromuscular health problem necessitating treatment," the policy indicates.

A similar policy from Noridian Medicare, another Part B MAC, advises chiropractors to enter up to four diagnosis codes in priority order (two primary and two secondary conditions). "If you need to document more than four diagnosis codes, as will be the case any time there are more than two regions billed, the additional diagnoses must be present in the medical record," the policy states.

Here's how: Suppose a patient presents with a subluxation of the lumbar and sacral spine with degeneration of disc(s) in the lumbar region, and the chiropractor performs CMT to the lumbar and sacral spine (one to two regions, 98940). You'll report 739.3 (Nonallopathic lesions, not elsewhere classified, lumbar region) as the primary diagnosis, followed by a secondary diagnosis of 722.52 (Degeneration of lumbar or lumbosacral intervertebral disc), and a tertiary diagnosis of 739.4 (Nonallopathic lesions, not elsewhere classified, sacral region), advises Kenny Marvin, DC, CCSP, of Marvin Family Chiropractic in Pearl River, N.Y. "In the past, Medicare required that chiropractors needed to have an x-ray that demonstrated the subluxation, but that is no longer required," Marvin says. "You have to make sure you document all the essential features of your examination of the patient so you can demonstrate the diagnosis code choice (P.A.R.T.)," he says.

In black and white: According to CMS Transmittal 137, dated April 9, 2004, "Effective for claims with dates of service on and after January 1, 2000, the x-ray is no longer required. However, the x-ray may still be used to demonstrate subluxation for claims processing purposes." In lieu of the x-ray, the transmittal indicates that the chiropractor must specify "the precise spinal location and level of subluxation giving rise to the diagnosis and symptoms" in the patient's record.

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