How the Simplest Case Can Get Complicated for Medical Coders

by  Find-A-Code™
Sep 11th, 2023

Doctors, nurses, and other front-line workers are often heralded as the heroes of modern healthcare. Do not misunderstand; they do very good work for which they deserve recognition. But there are plenty of other unsung heroes in healthcare. The medical coder is among them. Even the simplest cases can push a medical coder to their limits.

The truth about medical coding is that even simple cases can quickly get complicated. There is a lot more to medical coding than looking up a CPT or ICD-10 code and entering it with a keystroke. Coders need to know, understand, and properly apply codes based on nuances that can take years to master.

Example: CPT Code 97124

The 97124 CPT code offers a perfect example of how a seemingly simple case can get complicated. This particular code is utilized to bill for massage therapy. It sounds simple enough, right? Yet things are not so simple when a medical coder starts to dig in.

First and foremost, massage therapy has a particular definition within medical coding. It involves applying massage techniques to relax muscles, stimulate soft tissue, or improve blood circulation. It also involves three specific techniques: effleurage, petrissage, and tapotement. Do you know what those techniques are? The medical coder needs to know.

Only for Physician or Other Qualified Healthcare Professionals

CPT code 97124 should only be used when a physician or other qualified healthcare provider is billing for the therapy. Not only that, but the therapy must also be conducted in a clinical setting. If the two conditions are not met, the code cannot be used.

The clinical setting concept should be easy enough to understand. As for qualified healthcare professionals, they include physicians, physical and occupational therapists, physical and occupational therapy assistants, and massage therapists. According to CPT codebook guidelines, it an individual who may legally perform that service based on scope of practice regulations. 

If the therapy is conducted by anyone else, it cannot be billed under CPT code 97124. The code also cannot be used for treatments that are not specifically covered under the medical coding definition of massage therapy.

Time-Based Billing

Next up is calculating billing units. Assuming a medical coder is confident that CPT code 97124 is the appropriate code for a massage therapy case, they must then determine how many units to bill for. This is not as straightforward as it sounds.

The code itself pertains to a treatment period of 15 minutes. But as with just about everything else in healthcare, massage therapy is seldom contained within tidy 15-minute increments. It is not as though doctors click a stopwatch, apply the therapy for 15 minutes, and click the watch again.

In order to figure out the total number of units to bill for, the coder must add up the total amount of time spent on massage therapy and divide it by 15 (one unit equals 15 minutes). A total of 30 minutes spent would be two units for billing purposes.

Yet another thing to consider is the eight-minute rule. If, after dividing the total time by 15, there is a remainder greater than eight, the coder can round up to the next unit. A remainder of seven or less requires rounding down.

Don't Forget the Therapy Modifier

Last but not least is the therapy modifier. CPT code 97124 requires a modifier that could explain where the therapy was conducted, whether it was part of a pre-existing care plan, etc.

An experienced medical coder who has worked with CPT code 97124 for years will generally not struggle with new cases. But for a new coder, even the simplest massage therapy case could get complicated. And now you know why coders deserve more recognition than they get.