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Massage receipt template for Supervision

hello everyone my name is Dr Marty Cotler thank you for attending this webinar I want to thank Dr seagull for inviting me to do the presentation I enjoy doing these and I hope everyone does too all right going to switch the slides you should see the slides changing across your screen today's topic is massage therapy how to add it to a practice and I'll tell you a little bit about myself before we get started I am a chiropractor I practiced for 16 years and about 10 years ago I started Target coding I'm the president and founder of the company I'm also certified in CBT coding and certified in healthcare compliance I write articles for a lot of Chiropractic magazines and I'm also a member of the American Chiropractic Association and the American Academy of professional coders I'm a speaker for the coding Institute Parker seminars foot levelers and I'm a guest speaker at many national and State Chiropractic Association conventions so let's get started with the advantages and disadvantages of including massage therapy to your practice there are pros and cons to this so uh let's go through a few of these first it's going to add another dimension and approach to your practice um as the doctor of Chiropractic you don't have to do the soft tissue work anymore now this may be restricted in certain States but Most states allow chiropractors to hire licensed massage therapists Most states allow medical doctors and osteopaths to hire massage therapists Most states allow massage therapists to work under the supervision of nurse practitioners podiatrists Physicians assistants and physical therapists so if you have a massage therapist working for you make sure they're licensed get a copy of the license make sure that they um are licensed to practice in your state so now in some states massage therapists are allowed to do other modalities like for example in state of Florida licensed massage therapists can also do ultrasound and electrical stem and they're licensed to be able to do modalities so please check into that so if you have a licensed massage therapist doing that and is able to do that in your state then the doctor of Chiropractic just focus on adjusting so it's going to add additional Services Revenue you can put together a whole marketing campaign on massage therapy to your practice there's some disadvantages you're going to have more overhead you're going to need more room and you may need to cover the malpractice costs of the massage therapist so those are a few of the things that you should be aware of now as far as you know setting up your uh setting up the situation you're probably going to hire the massage therapist as an employee you know you could have the massage therapist work with you as an independent contractor you could have the massage therapist rent space from you um you know so there are a few different Arrangements that you can create maybe you could even partner with a massage therapist and form a new Corporation so you should look into that but most of the time you're going to hire the massage therapist as a regular employee take taxes out you know just a regular employee and this allows you more Revenue potential and you have control of the situation you're going to have some more billing responsibilities and more malpractice exposure but overall it's pretty straightforward you as the employer you're going to do all the billing under the employer tax ID number and then the massage therapist is going to get paid a salary employer receives all massage therapy gross revenues less than massage therapist salary taxes and overhead or attributable to the massage services I strongly recommend you have the massage therapist sign an employment agreement which outlines the duties the responsibilities of the massage therapist the compensation arbitration non-compete non-solicitation sick pay vacation time health insurance continuing ed all of those things should be outlined in the employment agreement if you're going to have the massage therapist come in and rent space from you that's great you can get additional Revenue just from the rent the rent should be um fixed in advance it shouldn't be based on patient referrals it should be based on the fair market value in your area so you can rent space to the massage therapist you want to make sure that you outline everything that the massage therapist can do Under the rental agreement you want to put together a suas agreement if you don't own the building you want to check with your landlord to make sure you could sublet a portion of your office to the massage therapist now the massage therapist is is going to bring in his or her own patients massage therapist is going to take care of all the financial Arrangements directly with the patient you're not involved with that at all you're just getting rent you're just renting out a room to the massage therapist and again the rent should be um at least one year in duration uh should not be based on patient referrals or patient volume and the rent is based on uh one year uh duration and it's set in advance it shouldn't be fluctuating every month those are the standards but you know check with an attorney you must check with an attorney once it comes to subletting space or any type of uh contractual arrangements okay now let's talk about massage therapy being a medically necessary Insurance reimbursable Service versus a wellness type non-insurance reimbursable service there are two types of ways to approach this there are two types of massage services again a medically necessary Insurance reimbursable massage versus a Wellness Spa type massage which is not reimbursed by insurance so let's go through the medically necessary massage situation first first thing you need to do is a history you need to talk to the patient and you want to come up with a complete history again this is for something that you're going to build so if you're going to build an insurance company for massage you first have to do an evaluation so that includes history there are four types of histories you should see them on your screen the massage therapist is not doing the history here because massage therapist cannot bill out for enm codes we're talking about billing out for a medically necessary service so we have to create create the foundation here with a history so example Mrs Jones how did the problem start when did it start so you have to go through a history there are four types problem focused history that would equate to cpg code 99201 an expanded problem Focus history well that's 99202 a detailed history is 99203 and a comprehensive history is 99204 and 99205 so let's just talk a little bit about the detailed exam you see it on your screen there detailed is 99203 so well I could tell you 99203 is the most commonly buil new patient cpg code now I'm talking about MDS the osteopaths chiropractors all the providers nurse practitioners you put them all together those are the doctors that bill enm codes well 99203 is the most commonly build so most of you listening to this presentation are using 99203 so that means you did a detailed history you see when you build an insurance company whether it's Medicare Blue Cross Blue Shield eus Signa United Healthcare all states sign you know Pi cases workers comp you Bill 99203 you're telling the insurance company a lot of information you're telling them you did a detailed history what's a detailed history hopefully you all know what this is if you don't let me share with you that means you have written down or you've entered into your system your computer software program at least one Chief complaint four hbis two to nine systems were reviewed and one item from the past history family history or social history was documented you must have those four items again at least at least one Chief complaint four hpis now HPI stands for history of present illness in Chiropractic colle you may have been taught this as the opqrst so you need four of those so I'll give you an example Mrs Jones says she has a pain radiating down her leg it's throbbing um it's worse in the morning and Ice makes it feel better those are examples of hpis so you need four of those next System review you have to review Systems you're required to review Systems with the patient there are 14 systems in the body there's the muscular skeletal system hey that's the one we're going to be focusing on but there's also the respiratory cardiovascular GI gu constitutional which is your Vital Signs ears nose mouth throat hematologic lymphatic there's a lot of systems in the body we're focusing on the muscular skeletal system system so you're going to need to do a little bit of System review 2 to9 systems need to be reviewed and one item needs to be reviewed as far as the past history family history or social history a past history example might be patient stated that she's never had any trauma to the spine family history patient stated that her mother has osteoporosis and osteoarthritis social history patient smokes cigarettes drinks alcohol socially on the weekend exercises three times per week so make sure you're documenting the history properly the next step to proving medical necessity leading up to the massage being build is to do an exam must do an exam the doctor has to do an exam before for the page see the I look at the massage therapist as the receiver and the MD do DC is the quarterback so example chiropractor sees the patient does a complete thorough evaluation and now is the quarterback is going to throw a pass to the receiver the massage therapist and now the massage therapist sees the patient but the MD do o DC first has to evaluate the patient must do an exam here you see on your screen same deal problem focused exam is 99201 expanded problem focused exam is 99202 a detailed exam is 99203 comprehensive exam 99204 and 99205 so now let's go back to the detailed exam what is that you have to have 12 findings 12 exam findings they could be positive or negative for example uh range of motion in the neck was normal full range you get credit for a finding Vital Signs three Vital Signs count as one finding checking for range of motion counts as a finding um now here's where it gets a little tricky if patient comes in with low back pain and you say okay Mr Jones Bend forward that's lumbar flexion patient has restriction in pain then you say okay Mr Jones Bend backwards extension also restricted and pain inflection and extension does that count as two separate findings the answer is no whether they're all positive or all negative it counts as one finding Orthopedic neurological tests also all counts as one finding similar in the neck you do range of motion on the neck you do foraminal compression and then you do cervical distraction all of those findings whether they're positive or negative count as one so make sure you are counting up your findings properly so we have range of motion we have assessing for asymmetry and and joint laxity and subluxation we have assessing for pain and tenderness postural evaluation tissue and tone changes muscle spasm muscle weakness the skin skin if you see a rash or a lesion on on the patient's neck or back that counts as a f finding or just saying there's no scars rashes or lesions that also counts reflexes sensation pin wheel even a brief mental assessment stating patient appears to be oriented to time and place that counts as a finding so make sure you have 12 findings if you don't have 12 findings then you have to down code to a 99202 so that's a little bit about the exam findings there's a lot more but remember this is a this is a massage therapy the webinar so now comes the decision making after the exam after the history now you need to come up with the diagnosis remember this is for a medically necessary massage that we're leading up to you have to have a diagnosis so here just a little reminder or maybe this is brand new for some of you I don't know if this is a reminder but the definition of medical necessity portion the definition of medical necessity is a very long definition this is just a portion of it so portion of the definition of medical necessity says the items or Services being provided must be reasonable and necessary for the diagnosis of an injury or an illness to improve the functioning of a patient so the diagnosis is huge you have to use the most appropriate diagnosis codes so hopefully hopefully you're doing that this is um I just put up um a sample um page of a book this is a book that I strongly recommend everybody get it's called CPT diagnosis code linking so here's an example this is an excerpt this is one page out of the book massage therapy 97124 is the CPT code and then all the diagnosis codes here are listed well these are just a few there's I know probably 50 or 60 diagnosis codes that link to massage therapy so this book that I'm referring to gives you every 97 code that you would probably use in a typical Chiropractic or physical therapy practice like traction electrical stem ultrasound therapeutic exercises neuromuscular re-education therapeutic activities massage therapy manual therapy it lists the CPT code and all the associated diagnosis codes so make sure you're using the right Di diagnosis codes now this is an excerpt of one page out of the book please do not email me asking for a copy of this page that's not going to be given to anyone it's just for you to see how the book lays out if you're interested in the book then just send an email to Amy Target coding.com Amy Target coding.com and she can get you information on the book the next part of creating a a care plan that leads up to billing insurance for massages goals you need to set goals for the patient how do you start setting goals well take a look at the form you should have good quality patient intake forms you may be able to start Gathering Baseline numbers from the intake form just from talking to the patient ask the patient about how does this particular problem prevent them from doing their normal daily activities when you do an exam you're doing range of motion get Baseline numbers in the exam and set goals from there your goals have to be feasible they must include a time frame as the patient meets their goals you need to update them once the patient meets their ultimate long-term goal then you have to transfer the patient over to Wellness care and we're going to go over that specifically for massage Massage and Wellness is coming up soon after you set goals you're going to start outlining what you're going to do this is also part of decision making what are you going to do on the patient got a lot of choices in the typical Chiropractic or medical practice Physical Therapy practice you could do ice packs hot packs electrical stem traction manual therapy massage therapy obviously therapeutic exercises neuromuscular reeducation therapeutic activi ities maybe you're going to order DME x-rays do diagnostic testing like emgs and ncvs send the patient out for a consultation Chiropractic acupuncture strapping and casts kinesiotaping Orthotics spinal Orthotics foot Orthotics functional evaluations nutritional consultations weight loss programs lab work functional evaluations trigger point therapy there's a lot of things that you can provide but let's stay focused here on massage so you want to outline specifically that you're going to be doing massage why you're doing what's the clinical rationale you need to know the clinical rationale for massage there's a definition of massage that should be in your care plan that sets the table very important email us email Amy Target coding.com if you want that clinical rationale or that definition of Massage Therapy you're going to outline that where you going to do the massage how often the frequency and duration what part of the body for how many minutes per visit so that's all outlined it's not difficult once you get this figured out and you know what needs to be done it's very simple if you're hearing this for the first time you may be saying wow that's a lot of work it's not once you figure it out you know it's like I watch the uh the Food Network a lot and I see them making these uh you know these dishes and every time I you know you know I watch the the person making the the dish they the the chef always says it's so easy you just get a little onion a little garlic and they make it seem so easy and I'm looking at it because like wow this looks like a very complicated dish so once you get the recipe and you do it a few times yeah it's easy initially it sounds very difficult and complicated but once you do it a couple of times you're going to go wow I didn't realize this is this isn't too bad so next you want to outline the schedule of care patient's going to be seen how many times per week and for how many weeks you must outline a frequency and duration of care that's important as a matter of fact many insurance companies require it again we're talking about insurance reimbursable medically necessary massage most carriers want to see frequency and duration of care you have to outline now that's not a full treatment schedule that's a portion of the care plan now let's get into some specifics regarding billing insurance companies for the massage under the therapeutic procedur section of a typical CPT code book you'll see a manner of affecting change to the application of clinical skills and or services that attempt to improve function one-on-one contact is required each 15 minutes so the CPT code for massage therapy is 97124 97124 pretty straightforward this includes eage Petr Depot 97124 is the CPT code for massage therapy now do insurance companies pay for massage some do a lot do Medicare pays for massage when a physical therapist does it when a nurse practitioner does it an MD or do Medicare will not pay unfortunately Medicare will not pay a chiropractor for massage 97124 but they will pay a PT and many other healthc care providers so we have massage now massage should be used as a preparatory procedure to set the patient up for another procedure being done a therapeutic procedure that's going to restore function reduce edema that's the the expanded description of massage it's used to uh restore muscle function relieve spasm decrease stiffness now another CPT code that's associated with massage therapy work is manual therapy 97140 CPT code 97140 is manual therapy techniques example mobilization manipulation manual lymphatic dra drainage manual traction see there's manual traction that's different than mechanical mechanical traction is not 97012 this is manual traction so this is another procedure that most massage therapists are licensed to be able to perform there's a big difference between these two you can't do the same thing and build two different codes if you're doing massage you build for massage if you're doing manual therapy which is different than massage then you build manual therapy some providers can refuse that they'll say well I'll do the same thing but this insurance company pays for 97124 next patient I'll do the same thing but this company I'm just going to build 97140 because that's what they pay careful with that there's a difference between the two now here's another thing you should be aware of as far as 97140 and 97124 the national correct coding initiative edits created by Medicare require that manual therapy again 97140 and massage 97124 be performed in a separate anatomic site if you're giving the patient a chiropractic adjustment so therefore if you're going to do the massage or the manual therapy in a separate anatomic site than the Chiropractic manipulative treatment then you're going to add the 59 modifier to the 97140 or the 97 124 you're not going to add the 59 to the CMT so now let's say you have this all figured out you got it done you know what to do you send in the bill and then it comes back like this denied how do you prevent this denial benefits are denied because the diagnosis is inconsistent with the procedure what happened you did not use the right diagnosis codes if you want to learn which diag nosis codes are used with 97124 or 9714 that's the book that I was mentioning earlier so send an email to Amy Target coding.com and she'll get you information on this book that I'm referring to that's called CPT diagnosis code combining and that'll dramatically reduce any denials you're getting because of this comment here benefits are Deni because the diagnosis is inconsistent with the procedure for some staff members they don't know how to tackle that they don't know how to troubleshoot that they don't know what to do the doctor doesn't know what to do and then that's how the insurance companies win because they got away without paying you now I'm going to give you a little surprise quiz let's say you do 10 minutes of massage on the lumbar region and 10 minutes let's say of therapeutic exercises 10 minutes of each and then Chiropractic adjustment to C5 T1 and the right SI joint how would you build this can you build for both of those time Services see ing to Medicare one unit is 8 to 22 minutes but now I'm doing two Services 10 minutes each can I build both no you could pick 97124 or 97110 you must pick one of the other you cannot build both because you have to total up the amount of time spent doing all the time codes in this example you only got up to 20 minutes 8 to 22 is one unit so you'd only be able to build one unit or one code and then 98941 would be for the three region adjustment so just wanted you to be aware of a little bit about the billing requirements now here's a sample massage therapy soap note this is something that if you want to get a copy of this send an email to Amy Target coding.com Amy Target coding.com and she could send you this sample massage soap note it's very um straightforward it's very compliant it meets all the documentation requirements that most insurance companies are looking for this is something that the massage therapist would fill out and would get attached to the rest of the soap note if there's anything else being done let's say the chiropractor is doing an adjustment or the physical therapist ising doing some traction so you may have three different Health Care Providers seeing the same patient everybody has their own soap note you combine them all together but this is a sample massage therapy soap note you're circling here patient comes in low back pain low back stiffness feels at 75% of the day it's annoying it's stiff and rates it an8 out of 10 also complaining of neck pain and right SI joint pain feels it 50% of the day rates it a N9 out of 10 it's tight and sharp the third complaint is right shoulder pain rates it a five out of 10 it's dull it's stiff and feels it 25% of the day there's tenderness in the lumbar and cervical paraspinal muscles range of motion was decreased in right shoulder adduction assessment patient about the same what do we do we did massage on the lower back the right SI joint the neck and right shoulder for a total of 60 minutes we're recommending the patient come in one time per week so here we go treatment plan is one time a week massage therapist should not be changing the diagnosis without speaking to the doctor massage therapist should not be making any major changes to the diagnosis the care plan the services being rendered without speaking to the provider who's supervising the services that's why I mentioned before the massage therapist is the receiver the health care provider for example MDD o DC is the quarterback so the receiver cannot make any changes unless they check with the quarterback now let's talk about massage therapy for wellness care but you know before we even get that when you're calling to verify coverage you know again let's stick with massage for medically necessary purposes here you also want to do a insurance verification you want to call the insurance company to verify that massage or manual therapy is covered while you have the insurance company on the phone ask them if the massage is performed by a massage therapist does the chiropractor have to be on site can the massage therapist perform their procedure at all there are some carriers do not pay if the massage therapist is performing the massage even though it's within the scope of practice of the doctor so check with that when you're doing your verifications now let's talk about massage therapy for wellness care so Wellness care massage therapy has a wellness component Chiropractic has a wellness component Physical Therapy has you know most Services have a wellness component but what's Wellness what's maintenance well maintenance or Wellness care include services that seek to prevent disease promote health and prolong and enhance the quality of life or maintain or prevent deterioration of a chronic condition a wellness program consists of activities that preserve the patient's level of function and prevents regression of that function maintenance begins when the therapeutic goals have been achieved Wellness care is not typically covered by insurance so please understand the difference here here there's a difference between medically necessary Insurance reimbursable massage and a wellness Massage Wellness massage you know I'm sure those of you listening to this presentation there may be a hotel in your area a resort where people go for massages there's no insurance coverage for that you may have a franchise like Massage Envy in your area there's no insurance coverage for that so there's a big difference between Wellness care and active therapeutic medically necessary Insurance reimbursable massage now Wellness is getting bigger and bigger um it's more popular nowadays than ever before especially when it comes to the federal government to me it doesn't matter if you're a Republican or Democrat the the administration right now is doing more about prevention than any other Administration that I've ever been part of so recently the Health and Human Services announced $ 372 million Grant to 44 communities to support Public Health efforts to reduce obesity and smoking increase physical activity and improve nutrition the awards are part of the Health and Human Services is communities putting prevention to work it's part of the new era or the patient protection act or healthc care reform whatever you want to call it this is an unprecedented level of commitment to prevention investing in local communities will build a healthy America the aim is to reach more than 50 million people who are living in these communities so there's the website if you want to learn more about it there's a website um and you know you can see um more information if you go to uh Medicare or cms.gov and you could read a whole bunch of new programs in place now Dr Dean ornish I don't know if that name rings a bell to any of you medical doctor who specializes in uh nutrition and weight loss a portion of his wellness program is now paid by Medicare so Wellness prevention is something that's being addressed a lot now more than ever so now let's talk about massage as a cash service here melus let's continue to talk about it uh you know we've been talking about it um for a few minutes now so let's continue massage as Wellness as cash so let me just inform you that you could only do services that are within your scope of practice so if you're a massage therapist listening to this check your state board if you're a chiropractor medical doctor check your state board for the rules statutes and regulations regarding massage now massage is a cash servic is much less complicated than the insurance model you don't have to prove medical necessity to an insurance company you still have to prove medical necessity to your state board you still have to prove medical necessity to a malpractice carrier if there's ever malpractice situation involved but as far as insurance goes this is cash now if you're charging insurance for medically necessary massage and then you also have patients coming in for cash Wellness massages you gotta have the same fees should be the same fee for both shouldn't be charging more to Insurance just because they have insurance you can't charge more that's a violation now you could provide a little small discount or you can join a company like cyoh Health USA which is a discount medical plan organization that's something you can do where you can get a much bigger discount so on the transition visit from Active Care to Wellness care make sure to provide a little summary little discharge summary about going from medically necessary Insurance reimbursable massage to non-insurance massage tell the patient Mrs Jones good news and bad news the good news is you've reached maintenance the bad news is your insurance doesn't cover Wellness massages would you like to continue to come in here's the fee this is what you need to pay out of pocket this is not Insurance reimbursable because you're doing great and let the patient make a decision let's say they go yeah I'd like to continue to come in fantastic let's say a patient is not sure say you know what Mrs Jones we can let you go now we can discharge you if you have a problem in the future a flare up an exacerbation a new problem come back in and we'll start billing your insurance again could do that too let the patient go now when the patient returns and they had a triggering event like hey Doc I was doing great I went down to tie my shoes and now my back is killing me or hey massage therapist everything was going great just woke up this morning my neck is so stiff I can hardly move it so now we have a triggering event so now you want to set the table again by doing a History exam diagnosis start the wheel in motion again and now start billing Insurance again and now this is medically necessary Insurance reimbursable massage treat the patient for a while and then transfer them back to Wellness if you're going to have to bill the insurance company for a wellness massage some insurance some patients don't get it you know you tell them it's not paid by insurance that we're talking about Wellness massage a wellness massage is not paid by Insurance patient has to pay a pocket and they're paying you great now all of a sudden out of the Clear Blue Sky the patient says give me a bill I want to send it into my insurance and you say well no wait a second this is not insurance reimbursable this is a wellness massage and the patient says I don't care give me something I want to send it into my insurance great so then you can use hipic code s8990 okay just a couple of closing comments here you must check with all the carriers you build prior to submitting claims based on the information provided in this presentation to ensure that it is compliant Target coding does not guarantee that the information provided in this in presentation will guarantee payment from any insurance carrier or patient Target coding is not responsible for any insurance carrier or manag care organization laws rules guidelines that may change following this presentation please understand that insurance carrier laws rules and guidelines can change so it's important to stay your best stay on top of any changes that may occur by attending seminars webinars and joining your National and State professionalist