Q&A: Blue Cross Blue Shield Updating Their Policy on the Application of Therapies by a Chiropractic Assistant

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Oct 24th, 2017

ChiroCode recently received the following inquiry:

Blue Cross Blue Shield is updating their policy on the application of therapies by a chiropractic assistant. It is as follows:

"Physical Therapy and Chiropractic Billing Guidelines Reminder

Physician or Chiropractor “Incident To” Billing of Therapy Services (New)

Beginning January 1, 2018, physicians and chiropractors may only bill for physical therapy
services they personally performed. Services furnished by a physical therapist (PT) or physical
therapy assistant (PTA) under the supervision of a PT, which were previously billed under the
physician’s or chiropractor’s provider number, must be billed under the PT’s provider number.

Physical Therapy Services

In order to bill physical therapy services, the services must be provided by a person licensed to
perform the service and operating within the scope of their license. For example, technicians,
exercise physiologists, aides, chiropractic assistants, RNs, LPNs, etc. are not licensed to provide
physical therapy and therefore should not bill these services. A physician or chiropractor should
not bill for physical therapy services performed by an individual unlicensed to provide physical
therapy. A PTA must practice under the direction and supervision of a licensed PT and not a
physician or a chiropractor. Services performed by the PTA must be billed under the supervising
PT's provider number.

Direct Patient Contact Required for Therapy Services

CPT® codes 97032-97039, 97110-97160 and 97530-97546 require direct patient contact. Time
billed should be based on direct one-on- one constant contact by the provider with the patient.”

Rumor has it that this ruling is based on the Criteria of the Code books concerning these services. Are there any in roads to "a challenge on no rational basis" or "ruled to be discriminatory?"

Response:

Unfortunately, the guidelines which precede these codes in the CPT book says:

“Physician or other qualified health care professional (ie, therapist) required to have direct (one-
on-one) patient contact.”

In 2013, the American Medical Association (AMA) established a definition for a qualified healthcare
professional (QHP), in terms of which providers may report medical services:

“A physician or other qualified health care professional’ is an individual who is qualified by education,
training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”

The phrase that hurts chiropractic assistants is “independently reports that professional service.” Only
those with the license can submit the claim with their name on it.

On July 7, 2017, in the case of State Farm Mutual Automobile Insurance Company et al. v. Robert J.
Cavoto, Jr., et al., a Delaware County Common Pleas Judge rendered a decision that chiropractors may not delegate massage, manual therapy, and therapeutic exercises to unlicensed support personnel/staff. The Chiropractic Practice Act in Pennsylvania, where this case was heard basically just said that you can delegate as long as the unlicensed individuals were trained. Therefore the court basically provided a more specific interpretation of the act.

In a multi-million dollar lawsuit (which ChiroCode consulted on) in the New England area, the insurers used the CPT wording to argue that a group of clinics were billing fraudulently and should pay back hundreds of thousands of dollars. The rebuttal was that state scope rules, so, if you are in a state that specifically allows delegation to unlicensed staff, you might be able to argue against denials. But, typically, when you have signed a contract with a payer, you are bound to that contract.

Alternatively, the licensed chiropractor could supervise groups doing various therapeutic procedures.
One-on-one contact is not required, there is no time element, and the patients need not be doing the same exercise. In this scenario you could fire all of your unlicensed staff and get paid to do the service for several patients at once, thus preserving revenue. Note that 97150 - Therapeutic procedure(s), group (2 or more individuals) pays about half of the individual procedure codes, but groups can be larger than 2.

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Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I CPMA MCS-P CMHP
ChiroCode Vice President

About Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Dr. Gwilliam is a licensed chiropractic physician with a master's in business administration.  He is also a certified professional coding instructor, compliance specialist, and medical auditor.  He has published articles in multiple trade journals and travels the country to deliver training to physicians and staff on coding, documentation, and compliance.