Question

Can you please help me with the definition of Office Visit? We have used code 99213 E&M code for office visits. However, we have some insurance companies that will cover office visits but not chiropractic treatments. Can we bill for office visits even though we are giving chiropractic care? And, is code 99213 a good code to use for an established patient visit? Providence Health here in Oregon did not like us billing 99213 and using M99 codes along with this CPT code. They still consider it chiropractic treatment. Which it is but we did not use a CMT code. We charge a flat fee for office visits/treatments.

Answer

If you bill for an office visit on the same date as chiropractic treatment, you must append the 25 modifier to the office visit/exam code.  On this note, you must be sure that you are indeed performing a "distinctly separate" office visit, in order to bill and collect payment from this as a separate procedure.

Bear in mind also that there are different levels of E/M and you must be careful to have appropriate documentation so as to select and bill for the proper level of E/M.  I would encourage you to review the 1995 E/M guidelines so as to gain a greater understanding of these requirements.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

M99 codes are appropriate to support the 9894- codes for chiropractic manipulative treatment.  This is so unless the payor specifically identifies other diagnosis codes instead.  M99 codes would typically not support the E/M codes.

Note that many policies limit the number of office visit E/M services allowed to be billed so you must also verify benefits to ensure you haven't exceeded those limits.  Here are some detailed descriptions of the codes we are discussing:

25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service:It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99212 - Office or another outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.