There's other issues that come to the review and particularly what they'll say is bundling and unbundling of services. Certain services are bundled together. For instance, I know every chiropractor is familiar with. Evaluation and management codes have modifier 25 appended to them when billed with treatment because those codes would be bundled otherwise. That 25 is to demonstrate it’s separate. What we also have is what you see here on this slide. It says bundling and unbundling of services 97140. Every chiropractor is aware of 97140 and the problems with that code. That code, of course, is for manual therapy. Manual therapy, of course, includes a lot of varied services. It could be manual traction, joint mobilization or even mile fast release. All of which were very good services but the problem with that code 97140 is that it is not reimbursable separately from your chiropractic adjustment if it's done in the same area and that's what they considered bundled. To show that it's not bundled that code would require modifier 59 to demonstrate it's a separate area. The same applies to 97124 which is for massage, or, for instance, 97112 neuromuscular education. While those two services do not require a separate region, you would want to make sure you're indicating the separate performance that is not part of another therapy. Let's look more closely at this manual therapy. Manual therapy, again, rule number one, must be to a region not manipulated on the same visit and it must be appended with modifier 59. Using the 59 alone is not enough. You must also make sure your documentation will always demonstrate that the manipulation occurred to a region where there is no manual therapy. This is a very common reason for a review or request for records. Most audits start with the simple review of one patient or one claim but based on that review if they see a discrepancy they clearly are going to want to look to say, “We'll let's see what other providers or what other patients you've done with the same.” Make sure that you can always demonstrate the separate nature of it. The other factor, of course, beyond just documenting the services is medical necessity. You'll see here we have outcome assessment tools, disability indexes. These are the tools that many of you are using now for Medicare. They're requiring these so-called functional assessments like an Oswestry or low-back index or a neck disability index. These are simple forms that patients fill out. What the patients do, they fill them out, the doctor scores them, and it tells us how the patient is progressing.
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