Hi everyone. This is Sam Collins, your coding and billing expert for chiropractic and the HJ Ross Company. Your place for seminars and coding and billing help. On today’s episode, I’d like to talk to you about what is the difference between a therapeutic exercise 9 7 1 1 0 or a therapeutic activity? 9 7 5 3 0. They’re often confused and it’s understandably so, because many times we’ve, didn’t learn that. Think back for most of you. At least when I went to chiropractic college, we had 120 hours of physical medicine, which certainly didn’t include all the nuances out there. So we always have to look a little bit more for information. Well, the focus, as I said will be on those two codes, but I want to start with let’s focus on the type of care plans that are expected. So I’m going to give you two areas or two companies that have made a direct focus on what type of care is expected in the longterm.

Now this, again, chiropractic adjustment during any phase of care is useful, but what about the therapies we may do? So I want you to take a moment just to listen to what Anthem has to say about active care and chiropractic. And here’s what they indicate treatment provided is to alleviate pain as a directed, to limit the extent of injury or condition, reduce the signs and symptoms of inflammation and to minimize functional disability. And it says the short term use of adjunctive therapeutic modalities procedures may be appropriate in addition to manipulate, putting them into manipulation. And it says this significant improvement is for the patient has there. Then another phase of care should begin. However, that’s phase one limit the pain, kind of the modality phase, you know, pains, spasms so forth, but phase two, it says this treatment provided is directed to focus on improving pain-free ranges of motion and restriction of function to the fullest extent possible promoting structural integrity and invoicing the conditioning.

It goes on to say frequency of treatment and use of therapeutic modalities typically decreases according to the progress. So certainly when you go from phase one, which would be pain reduction factors, you know, modalities passive, we get now to a little bit more active care to try to increase the strength of flexibility, if you will kind of rehabilitation. And again, rehabilitation takes on this big term, but I want to focus in on rehabilitation, meaning restoration to pre-injury status. Now let’s go on to see what it says about page phase three. It says treatment per prided to direct focus on promoting the restoration of strength, endurance, and performances of activities necessary for daily living. So you notice with the three phases of care, it indicates the first phase certainly is pain management, getting the patient comfortable, again, you know, getting them to be able to sleep with that.

If nothing else. However, notice two of the three phases focuses in on active care, meaning the rehabilitation. Now we often think, well, what is this rehabilitation? Is that an adjustment? Well, it’s certainly part of it, but that’s not the only part. There’s gotta be more to it in the sense of physical medicine. And if you think of it, if you go to a physical therapy facility and I’m sure you’ve all seen one, have you noticed how much they have changed? Now? Back when I was in chiropractic college in the early eighties, very different. In fact, for those of you, as old as I am, you might remember the Merck manual said, if you have back pain, you should lie in bed. In fact, I thought that was laughable. And it wasn’t until about mid 1980s, that physical therapy embraced this active care model that chiropractic had always done since 1895, for that matter.

Well, that being said, what is the focus, your physical therapy. Now notice if you look at a physical therapy facility, now, if you go up and look through the window, what you’ll find is it’s a gym. They’re mostly doing active care, meaning something the patient is participating in, not passively happened. Having happened to them now within this, I want to go further. Now, the first one I gave you was an Anthem policy. I want to delve further to the Cigna policy. What I’m trying to do is to give you from the standpoint of the persons that are going to reimburse, and here’s what Cigna says in their chiropractic policy. It says this, the provider should attempt to integrate some form of active care as early as possible continued use of passive care modalities may lead to patient dependency and should be avoided. So I look at that and I think my goodness, what they’re really saying is you want to limit the amount of passive care and focus more on the active care.

How I look at that from a billing and reimbursement standpoint, they’re basically saying, don’t do the passive cheap services focus more on the active, more expensive services. And in many ways, from a pure billing and reimbursement standpoint, I’m kind of like, well, yes, that sounds good. But in fact, forget the billing. Let’s talk about patient response. How is your patient going to respond to care if you rehabilitate it and strengthen it, not just get the joint to move better, but to make sure it’s stable and functional. So it goes on to say this passive modalities may be helpful in the short term relief of acute signs of inflammation. And it says the utilization of passes Medallia is not considered medically necessary for the acute phase, except for the acute phase. So keep in mind, carriers are pushing that we focus more on active care, but within that, I think why are we not pushing that to give you an idea?

Active care is paid at a much higher value than does passive because it’s more interactive. It’s more one-on-one. So the reality is they’re basically saying don’t do the inexpensive services, do the expensive services. So why do we fight back on that? I think we push so much in our profession for manual therapy and massage and there’s places for that, but it’s passive. What about active rehabilitation? Well, that brings me to the codes for exercise in therapeutic activities. What is the difference? And this is the part I think many of us never really understood the nuance. So again, those of you who have been around a while, you might remember, we used to have a code that was called functional activities. And the code I believe was 9 7 1 1 4. Now that was updated, oh gosh. In late nineties, two nine, seven, five, three zero, which we now call therapeutic activities in many ways.

I wish we had kept the term functional activities because that’s really, when you hear the term therapeutic activities, that’s what you should think of. So let’s define what is exercise? Well, exercise says it’s to develop strength, endurance, and range of motion, flexibility. So it’s what you think it is. Increase a person’s strength. Maybe they’re doing abdominal curls to strengthen their core. Maybe they’re doing back extensions or they’re hamstring stretching. Those are all single parameters. And that’s what exercise is exercises to restore a single parameter activity. Like a person has very tight hamstrings. So you stretch their hamstrings that’s exercise. Maybe the patient has a very weak core. So you’re doing abdominal curls to strengthen that that’s exercise. So your typical weightlifting, whether it’s isometric isotonic, ISO, kinetic, dumbbells, and free weights, and all of those things could certainly fit. But think along the lines of exercises there to restore one parameter strength or flexibility or endurance those factors.

Now that’s the difference of a therapeutic activity. And this is where things get a little different. A therapeutic activity says this it’s the use of dynamic activities to improve functional performance. And so often what you’ll hear is that a functional activity or a therapeutic activity is we call it an ING, meaning reaching, bending, twisting things that end in ING. So a functional outcome, by example, a friend of mine, that’s a physical therapist. One of the ways that he described the difference of exercise to a therapeutic activity is more about the outcome. And the more I researched that, the more that I saw that that’s how it was related within the profession. And in fact, the American physical therapy association defines the same way. So in many ways, could a therapeutic exercise and a therapeutic activity be more or less the same thing in many ways.

Yes, but it’s more, what are you looking for an outcome? So here’s the difference he gave me. He might have a person that has weakness in their lower back. So they’re picking up a weight from the Florida waist to strengthen their back. However, let’s take the same activity, but it’s there because the person’s job, or maybe they have a small child that they cannot lift. And that activity is to focus on their ability to do that activity, to pick up something from the floor, then it becomes an activity. So in many ways it’s more about the outcome. And I’d like for most chiropractors to think for a moment when you’re doing exercise with your patient, are you really just doing one parameter? Are you just solely trying to strengthen the abdominal muscles? Let’s say, or are you strengthening the abdominal muscles so that the person can get up from a lying down position or stabilize themselves sitting or do something where they can bend and pick up something from the floor that activity then moves towards a therapeutic activity because it has a specific functional goal, not as simple goal of strengthening, just a single muscle.

By example, let’s say you have a person that’s a tennis player and they have some type of elbow injury and you have them doing a tricep extension just to strengthen the tricep muscle. That would certainly be an exercise, but what if you have them doing that? But you’re adding motion to it with a tennis racket to restore their ability to hit a ball that becomes a therapeutic activity. And in many ways, I want you to think of a therapeutic activity is just simply more goal oriented. You’re doing something designed specific for your patient to restore a particular type of activity or movement they’re necessary. They need to do necessarily within their life. So think in these terms, the difference of course is the reimbursement 9 7 1 1 0 has a relative value of 0.8 7 9 7 5 3 0 has a relative value of 1.15. And to give you the difference there, because you may say, Sam, what are relative values?

Relative values are simply the value of one service compared to the other. So I think you can immediately see the relative value of 9, 7, 5, 3 0 is substantially higher. And in fact, to make it in the simplest term for a doctor of chiropractic 9 7 1 1 0 has the approximate value of 9 8, 9, 4 0 simple one to two region manipulation, whereas 9 8, 9, 4 1 and 9, 7 5, 3 0 have approximately the same value. So that generally means about a 30% difference. So in many ways, if you’re doing exercise great, that’s what a patient needs, but is what you’re really doing more a therapeutic activity, or is it exercise? And I’m not going to say it’s absolutely one of the other, but think of what is your goal? What’s your purpose? I have a hard time believing most chiropractors do single parameters. I think we’re always looking for what are we restoring back for this person to do within their lifestyle?

So in choosing these codes look more to not you’re doing, but why you’re doing it. And then of course documenting what you’re doing. Remember both of these codes, 9 7 1 1 0 1 9 7 5 3 0 are timed services, which means they’re 15 minutes, which means it follows the eight minute rule. Now, remember the eight minute rule says this, you must spend at least eight minutes face-to-face with the patient doing it. Now let’s understand when they say face-to-face, does that necessarily mean you are touching the patient? Absolutely not. You could be directing them. You could be watching to make sure they’re doing it safely, making sure they’re doing it within the ranges that are necessary to achieve the goals. So it doesn’t necessarily mean touching, but it doesn’t mean one-on-one which means you cannot do two people at the same time. Now, if you have an additional therapist in the office doing that or an assistant.

Absolutely. But again, it has to be one-on-one. And remember the eight minute rule does indicate that you must spend at least eight minutes for one unit, but now the tricky part is what happens when you get to two units? Well, the eight minute rule says it must be at least 23 minutes. Therefore it’s 15 minutes plus eight for the second unit or for a third unit. It’s 30 minutes plus eight. So it’s eight minutes into the next phase. My key factor for you though, is getting a good understanding that are you really doing exercise or are you doing a therapeutic activity? Now, many of you that may be a network member with me, or I’ve been to a seminar we’ve gone into more depth with that, and this limits the amount of time, but don’t be afraid to kind of reach out to say, Hey, wait a minute, let me look a little bit more information here.

So if you’re a network member with me, been to a seminar, reach out directly and say, Hey, Sam, I want to get a little bit more information. I wasn’t clear, or I want to talk about documenting. And I’m certainly here to help within that. But what I want to focus on is making sure do you really understand those codes? And in fact, this will be for another time. What is the difference of 9 7 1 1 2? In fact, they often can be the same, but there’s again, there’s a nuance of outcomes. What my focus is for you is rehabilitation for your patient, not just adjusting. Now, I’m not saying the adjustment is not the most important thing, but partly to stabilize. Are you not doing exercises with these patients and are those exercises more therapeutic activity or are there an exercise once you to understand the definitions? The values are certainly much higher for one than the other.

And it makes sense to me, I think a therapeutic activity should be a higher value. Why? Because it’s a very specific program for your patient. It’s not generic. And I think most of you probably do not do generic programs for your patient. Not everyone gets the same list and goes, okay, just do this. But you do things a little bit differently for each patient because your outcomes are to be different. So from that standpoint, don’t be afraid to code properly. Meaning is it a therapeutic activity versus an exercise when you consider this a 30% difference as well for reimbursement? And lastly, I’ll say this, it’s what the carriers expect. One of the issues we deal with, I do a service call the network as a member, you can call me and email me with questions. One of the issues I get quite a bit is the insurance company has pushing back because they’re saying I no longer within the phase of care.

And often that meaning is you went from passive to active to show the rehabilitation part or the outcome for the patient. So again, understanding the codes can make a world of difference on reimbursement and on what you’re to do. Remember you still have to document the time document, what specific exercises or activities, you know, the w the sets, the reps, the weights, but it’s not that complicated, but it is simply indicating how the patient is getting an outcome. I’m happy to say doctors of chiropractic have always been the rehab specialist, in my opinion, as you well know, my father was a chiropractor and exercise or exercise activities have always been a big part of chiropractic. Let’s not lose that and fall into the trap of not understanding the codes we’re using and being over-reliant on passive care that they pushed back. Remember passive care like massage.

You got to do the separate areas. Remember exercise therapeutic activities do not require any special modifiers or separate regions. I will note, obviously if you’re billing United healthcare, the VA Medicare, or in many places, blue cross blue shield, you do now have to indicate GP G as in George P as in Paul on therapies, because it’s an always modifier and always therapy modifier. But outside of that, there’s no special things that need to be done other than indicating the services you provided. So give yourself a chance to reevaluate your program. Am I doing the right types of services? If you need some help, get in touch with me, take a look at our website, HJ Ross company.com. We offer seminars. We offer one-on-one services for members that you can deal with me on a one-on-one basis. Hey Sam, can you review this? Can you take a look to make sure it’s compliant? One of our big issues is making sure you’re compliant. That’s what ChiroSecure is about as well, emphasizing and increasing your practice, but without the risk, because we’re giving you the right parameters of coding and billing. So I want to say with that, thank you very much. Next week. There’ll be Sherry McAllister. That’ll be coming up, but again, don’t be afraid to take a look at our site. HJ Ross company.com. Get in touch with me. Let me be your expert. Look forward to seeing you next time my friends take care.


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