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CPT Coding Issues and Answers
From Terminology to Scope of Practice

By Vivian Madison-Mahoney

Originally published in Massage Bodywork magazine, February/March 2007. Copyright 2007. Associated Bodywork and Massage Professionals. All rights reserved.

Now, more than ever, massage therapists across the nation are asking about CPT codes--what codes to use and if they can use them at all.
I find in speaking with massage therapists, even though they are asking for CPT codes, many do not know what they are or what the difference is between a CPT code and an ICD-9 code. So let's begin with explanations of both.


Codes Explained
Current procedural terminology (CPT) codes, a numbering system set up for establishing types of treatment provided by medical providers, were developed by the American Medical Association (AMA) several years ago. Each year the AMA updates its CPT code book, but only a few of the thousands of included codes apply to massage therapists.

There are several categories in the AMA code book, but massage therapy falls best under the "Medicine" section. An example of a CPT code widely used by massage therapists is "97124--Massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion)." Another CPT code massage therapists use is "97140--Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes."

A misconception among many is that there is, or should be, a code for every individual service we provide. While there is hope that this may happen in the future with ABC Coding, the fact is that most of our techniques fall under manual therapy or massage therapy, which in some states is defined as soft-tissue manipulation.
There are a variety of codes that a massage therapist might be able to use, but only under certain circumstances. For example, Florida's scope of practice allows for the use of approximately twelve to fifteen different codes by massage therapists. When using any code, one must be sure it's designating a procedure or modality used within the therapist's scope of practice and training.

While we often hear we cannot use a specific code because it is not in the "Medicine" section, or that the codes are not to be used by massage therapists because they are physical therapy codes, let me assure you, this is not true.

Following are some excerpts from the AMA 2007 CPT code book:

- "It is important to recognize that the listing of service or procedure and its code number in a specific section of this book does not restrict its use to a specific specialty group."
- "Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified healthcare professionals."

Still, as we will discuss shortly, there are many codes within the CPT code book that fall way outside our scope of practice and are more applicable for physical therapists or other providers.

ICD-9 stands for International Classification of Diseases, 9th edition. The ICD-9 is a diagnostic code used by medical doctors to designate body locations of injuries and ailments. Since massage therapists are not allowed to diagnose, it is important that a diagnostic code is included on any prescriptions that accompany a physician referral.

In order for insurance companies to reimburse for massage therapy or any medical service, the condition being treated must be medically necessary. The way insurers initially determine medical necessity is by the diagnosis, designated by a code corresponding with the medical condition provided by the treating physician.

Some examples of ICD-9 codes massage therapists might see from physicians include "847.2--Lumbar sprain/strain" and "847.1--Thoracic (dorsal) sprain/strain."


Scope of Practice and CPTs
I cannot stress enough that when using CPT codes, make sure those you use reflect your training and scope of practice. Do not operate outside your scope of practice, and follow meticulous billing procedures. If you use codes to bill insurance companies that are outside your scope of practice and training, you may find yourself with disciplinary actions taken from your licensing or governing bodies. Trust me, you do not want to find yourself in a court of law, before your licensing boards, or before an auditing or fraud unit of an insurance company trying to explain why you are operating outside your scope of practice.

When I first looked at the AMA CPT code book in 1984 and saw the thousands of codes available, I had to decipher which were best for my training and scope of practice for the state in which I was licensed. When writing my courses and manuals to instruct therapists on how to bill insurance, I had to include all codes that a massage therapist might be able to use. It's important that every individual working with CPT codes deciphers which of those codes are in their own scope of practice and training for their state licensure or
certification.

For instance, if your state statute and scope of practice does not allow you to perform ultrasound or hydrotherapy, even though those codes are in the CPT code book under the "Medicine" section, you would not use them.

Therapists find themselves in trouble when they use codes not in their scope of practice, when the codes used do not reflect the treatment they provided, when the codes used do not coincide with their documentation, and when codes used do not reflect what the physician has prescribed.


Another Kind of Business
We all went to massage school to become a therapist. We take continuing education courses to remain a therapist and keep our licenses and/or certifications current. But most of us do not comprehend that when accepting medical cases and insurance, it requires some schooling, in and of itself. This takes learning the ropes of working with insurance company adjusters, physicians, and lawyers, as well as other aspects of insurance billing. It's much more than just knowing CPT or ICD-9 codes or possessing a specific type of form.

Dealing with insurance is an ongoing process of education. I have spent twenty-two years at this and am still learning. If you are willing to learn the ins and outs of working with medically-oriented patients and insurance, and learn to bill fairly and appropriately, you will find this to be a rewarding adventure, both financially and emotionally. Helping others is the name of our game. The better you understand and play the game, the more people you can help, the more you will prosper, and the better you will feel.

Vivian Madison-Mahoney, LMT, is an insurance consultant to massage therapists. She can be reached at vivianmadison@aol.com, or by phone, 865-436-3573. Visit her website at www.massageinsurancebilling.com.




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