Aetna has been denying manual therapy (97140) performed by a Chiropractor even with a 59 modifier. What can I do to get this service paid?

Aetna has made a nationwide policy decision for Chiropractic that when manual therapy (97140) is performed on the same DOS as a Chiropractic Manipulative Treatment (98940-98943) that the service will automatically be denied. Your options would be to perform the manual therapy service on a different DOS than the adjustment OR to submit the services together, anticipate the denial, and submit an appeal with your treatment records.

Aetna’s rational e for automatic denial is because of a review made determining that 90% of audited patients receiving manual therapy the same day as a CMT were having the services performed on the same region(s) even though the 59 modifier is supposed to be utilized only when the serviced is performed on a different anatomical region.

To avoid further scrutiny and audits, be sure that your appeal supports the following:

1.      1.  Indications for treatment (manual therapy)

2.      2. Treatment goals associated with manual therapy services

3.     3.   Objective measures being used to ensure patient is progressing in treatment goals

4.      4.  Progression towards treatment goals

5.       5. Document which regions specifically were treated with manual therapy and with your CMT – these areas should not coincide if you are attempting to receive separate reimbursement

6.       6/ Treatment plan (including frequency and duration)

Draft a brief appeal letter to be used as a cover sheet for your documentation. Save as a Word document so you may modify for continued use on Aetna patients. Your appeal letter should state that the 59 modifier used was to document that the manual therapy was performed on a separate anatomical region than the chiropractic manipulative treatment and your enclosed records disclose the treatment areas and supporting documentation for medical necessity for the manual therapy service.

Set a tickler or reminder for you or your billing staff to check on the claim(s) appealed after 30 days to see if a response has been provided and if not, contact the insurer to check on the status of the appeal and ask if additional information is needed to support the separate reimbursement of the service.

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