Print Page | Contact Us | Sign In | Register
Share |

WCA Successfully Challenges Improper Payment Denials by West Bend Insurance/Optum

July 22, 2020

The WCA has successfully challenged improper payment denials by West Bend Insurance and their utilization management company Optum for Neuromuscular Reeducation - CPT 97112 claims by chiropractors. The WCA sent a letter to West Bend Insurance in early June 2020 pointing out “...we see no support for your interpretation that the 97122 service should be “bundled” or is included in the
manipulation code.
” Optum replied to the WCA (see letter on page 41) on June 26th, 2020 and agreed with the WCA saying “The denials associated with CPT 97122 when billed during the same session and in the same region as the CMT service were in response to a longstanding NCCI edit. Only recently did NCCI provide notification that this edit has been deleted. The notification date was 4/1/20 with the end date for the code pair made retroactive to 1/1/20. In response to the deletion of this edit, Optum will no longer issue denials, sourced to NCCI, when CPT code 97122 is billed with a CMT code.” The letter goes on to direct providers to submit a request for reconsideration of the denied service through the insurance carried. A sample request for reconsideration letter can be found in the link below. “We appreciate being able to collaboratively resolve this issue with West Bend and Optum and assist our members in being paid properly for the services they provide,” said John Murray, WCA Executive Director and CEO.


Reminder: Medicare 2% Payment Adjustment (sequestration) Temporarily Suspended

June 4, 2020

As a reminder, Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspended the 2% payment adjustment currently applied to all Medicare Fee-For-Service (FFS) claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020. As a result, Medicare Fee-For-Service claims with dates of service on or after May 1, 2020, will not incur a two percent sequestration reduction in Medicare payment

Humana Medicare Advantage Cost Share Waiver Does Not Apply to Chiropractic Services

June 4, 2020

Humana has joined the list of Medicare Advantage plans who are waiving member cost sharing. In the case of Humana, the member cost share waiver does not apply to chiropractic services.

A Humana Provider update states, " Member cost share for all  in-network primary care visits  is waived for the remainder of the calendar year to encourage members to seek needed care from their  primary care provider This applies to Humana individual or group Medicare Advantage members. We want to encourage our members to reconnect with their PCP, particularly for preventive care and chronic condition management. Cost share waivers are retroactively effective as of May 1, 2020.  These cost share waivers apply to office visits for all participating/in-network providers as well as any labs performed in the primary care physician’s office during the visit . Labs drawn in the PCP office and sent to a hospital or reference lab are excluded from the primary care cost share waiver, as are radiology, supplies and Part B drugs administered as part of the visit. In support of this waiver, please do not collect a copay from any Humana individual or group Medicare Advantage patients for any of the primary care visits outlined above."

Since Medicare Advantage plans only cover active treatment manipulations, a DC cannot be a PCP for Medicare Advantage plans. According to Humana, the cost share waiver only applies to PCP visits and labs performed in the PCP office as part of that visit. Chiropractic clinics should keep collecting member copays.


UnitedHealthcare Waiving Cost Share for Medicare Advantage Members for Both Primary and Specialty Care Office Visits

May 11, 2020

For dates of service starting May 11, 2020 through at least Sept. 30, 2020, UHC is waiving cost share (copays, coinsurance and deductibles) for their Medicare Advantage plan members for all office-based professional services performed by both primary care physicians and specialists. Eligible services include Medicare-covered chiropractic services (just active treatment 98940-98942), primary care physician office visits, specialist physician office visits, physician assistant or nurse practitioner office visits and more. For more information and a complete list of eligible services, please click here.

The waiving of cost share for Medicare Advantage members applies no matter the diagnosis or reason for the visit. Patient cost share is waived for covered services from a network provider or covered out-of-network services.

What does this mean for you? Effective for dates of service 5/11/2020 until 9/30/2020 or beyond, you may not collect copays, coinsurance or deductibles for UHC Medicare Advantage members for active treatment 98940-98942, even if you do not have a Participating Provider contract with UHC. Commercial group plans and Medicare supplement plans are not included at this point in time. UHC will be paying what would have been the member cost-sharing to Providers. For any specific questions, please contact UHC directly at 800-523-5800.

Original-Medicare non-covered services such as exams and therapy modalities will continue to have member cost sharing. Ensure you append the -GY modifier to these items to communicate to UHC that they are non-covered services.

Information on Providing Telehealth Services

April 13, 2020

As healthcare providers, chiropractors are exempt from Wisconsin Gov. Tony Evers’ Stay at Home order which was implemented on March 25, 2020. What this means is that chiropractic clinics can decide on an individual basis to remain open or not. There is no doubt that treating patients with acute musculoskeletal conditions serves a vital public health need and prevents those patients from having to utilize urgent care facilities or the ER. WCA has compiled best practice safety guidelines for clinics desiring to remain open on our COVID-19 Resource page here.

As businesses adapt to the new COVID-19 landscape, many healthcare providers are adding telehealth services, or “virtual visits” to their clinics. Chiropractors are allowed to consult with their patients using telehealth in Wisconsin. While Medicare & Medicaid will not cover telehealth services provided by a chiropractor, some commercial payors will. Furthermore, if a Wisconsin state-governed health plan pays physicians or osteopaths to conduct a telehealth visit, they have to pay chiropractors as well. This is established via the Wisconsin insurance equality statute 632.87(3).

The WCA has been in contact with the Wisconsin Office of the Commissioner of Insurance to discuss coverage of telehealth services provided by chiropractors and proactively ensure that the insurance equality statute would apply to the provision of telehealth services. The OCI agrees that the insurance equality statute applies to telehealth services.

Here are some guidelines for providing telehealth services:

  • Check with your malpractice carrier to ensure coverage of telehealth services.
  • Informed consent still applies.
  • We highly recommend you review the WCA webinar, “Telehealth 101”, presented by Dr. Tim Bertelsman from ChiroUp. This helpful webinar provides a detailed overview of telehealth visits. Topics covered include: situations where telehealth can be useful to chiropractors, privacy concerns & HIPAA compliant telehealth platforms, potential pitfalls, state, federal & professional guidelines that apply, coding guidelines specific to telehealth, documentation tips & best practices. There are also resources such as sample forms that can be accessed following the webinar courtesy of ChiroUp.
  • Prior to providing telehealth visits, always contact individual payors to find out if they cover telehealth visits performed by a chiropractor and if a -95 modifier is required.
  • Note: if a payor states that they cover telehealth services when performed by a physician or osteopath but they do not cover the same service when performed by a chiropractor, please document the call and reach out to the WCA so we can notify the OCI of a violation of the insurance equality law. You can email the WCA Help Desk or call 608-256-7023.
  • Review the Additional Resources below.

Telehealth CPT Codes

Below are CPT codes which can be used for telehealth.

99441 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

99442 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes

99443 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21-30 minutes

*Established patient & new patient E/M codes can be used provided that more than 50% of time is spent counseling the patient.

Per the AMA coding guidelines:

  • the patient must initiate the service
  • services must be medically necessary
  • these codes can only be reported once per 7 day period
  • do not report these codes on a day when other E/M services are performed

Applicable Modifier

Modifier 95 indicates a synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. The 2020 CPT manual includes Appendix P, which lists a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio and video.

Telehealth Additional Resources COVID-19 & HIPAA

Telehealth and Home Care for Chiropractic and Physical Medicine Practices - Courtesy of PayDC Chiropractic Software

Billing for Telemedicine in Chiropractic - NCMIC

WCA Help Desk Webinar: COVID-19 

March 24, 2020

We had hosted this complimentary webinar for all Wisconsin Chiropractors to discuss the recent COVID-19 impacts on Employment and FMLA

- Click here to view Presentation Slides

- Click here to watch the Recorded Webinar

WCA Help Desk Tip: Medicare Advantage Plans Versus Medicare Supplements

February 4, 2020

There are many notable differences between Medicare Advantage plans and Medicare Supplements. Knowing these differences up front will help you and your staff avoid a lot of hassles and headaches.

What is a Medicare Advantage plan?

According to, the official U.S. Government site for Medicare, Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare. Patients who join a Medicare Advantage Plan still have  Medicare. These "bundled" plans include   Medicare Part A (Hospital Insurance)  and Medicare Part B (Medical Insurance) , and usually Medicare prescription drug (Part D). You may sometimes hear a Medicare Advantage plan referred to as a Replacement plan as well. Medicare Advantage Plans cover all Original Medicare approved services. Some Medicare Advantage Plans also offer extra coverage, like vision, hearing and dental. These plans are regulated at the Federal level, thus they are not subject to state insurance Mandates.

When it comes to chiropractic coverage, these plans will typically mirror the coverage offered by Original Medicare (i.e. they only cover active treatment 98940-98942). When you are verifying benefits, you can see if they have any additional coverage beyond this. Also check to see if the plan in question is an HMO plan. If so, and you are not in network, there will be no benefits paid by the plan with the exception of emergency treatment. You may want to ask if they recognize Medicare modifiers such as AT and GY. You will file claims to the company which administers the Medicare Advantage plan - do not file claims to Original Medicare.  Keep in mind that patients can go back and forth from Original Medicare and an Advantage plan, so it is best to verify their plan periodically. 

Only Original Medicare uses the Advance Beneficiary Notification of Non-Coverage (ABN) form - it doesn’t apply for the Advantage plans. Different payors may have their own version of the ABN form that they require the use of in situations where an ABN would be used with Original Medicare (prior to performing maintenance chiropractic care). In the absence of an official form approved by the payor, you can use this About Medicare Chiropractic Coverage form. When using the alternate ABN form approved by the company, it may be appropriate to append the -GA modifier to that service on your claim.

Lastly, covered services (just active treatment 98940-42) have specific patient balance billing guidelines from CMS which will depend on your status with Original Medicare.

• If you are a Contracted provider with the Medicare Advantage plan: there is no balance billing paid by either the plan or the patient

• If you are a Non-contracted provider with the Medicare Advantage plan, but an Original Medicare participating provider: there is no balance billing paid by either the plan (UHC or Humana for example) or the patient.

• If you are a Non-contracted provider with the Medicare Advantage plan, but an Original Medicare Non-participating provider: The Advantage plan owes the provider the difference between the patients' cost-sharing and the Original Medicare limiting charge, which is the maximum amount that Original Medicare requires an Advantage Plan to reimburse a provider. The patient only pays plan-allowed cost-sharing, which equals:
o The copay amount, if the plan uses a copay for its cost-sharing; or
o The coinsurance percentage multiplied by the limiting charge, if the plan uses a coinsurance method for its cost-sharing.

Non-covered services such as exams, modalities or x-rays can be billed to the patient at your full, regular fee unless you have a contract with the Medicare Advantage plan which prohibits this. UHC (AARP) is one company which discourages patient balance-billing of non-covered services; however, the WCA is currently working with UHC on this issue. 

Click here for a recent letter we sent to UHC which outlines the problem at hand.

What is a Medicare Supplement plan?

From A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that Original Medicare doesn't cover, like: Copayments, Coinsurance & Deductibles. Medigap policies are sold by private companies. Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care when you travel outside the U.S.

When treating patients who have Medicare Supplements, file claims to Original Medicare first. Medicare will pay its share of the Medicare-approved amount for covered services. Depending on your participation status with Original Medicare, many claims will automatically crossover to the Medicare Supplement policy, which pays secondary. Supplements will not pay until Original Medicare processes the claim.

8 things to know about Medicare Supplement policies:

1. Beneficiaries must have Medicare Part A and Part B.
2. A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
3. Beneficiaries pay the private insurance company a monthly premium for a Medigap policy. They pay this monthly premium in addition to the monthly Part B premium paid to Medicare.
4. A Medigap policy only covers one person. Spouses must purchase separate policies.
5. You can buy a Medigap policy from any insurance company that's licensed in your state to sell one.
6. Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can't cancel your Medigap policy as long as you pay the premium.
7. Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren't allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
8. It's illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you're switching back to Original Medicare.

Medigap policies don't cover everything. Medigap policies generally don't cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

If a Medicare Supplement / Medigap plan is issued in the state of Wisconsin, then it would be subject to the mandate for chiropractic coverage (see state statute 632.87(3) as well as Ins. 3.39(5m)(9) below). Some offices will include these statutes in a cover sheet when they send claims. However, there isn’t any specific wording in the laws that requires insurance companies to reimburse your full fee (see Ins. 3.39 which uses the term usual and customary). The main concept which applies is that these laws require insurers to process claims in the same manner for DCs as MDs and DO’s. So, an insurer couldn’t apply “usual and customary” reductions only to chiropractic claims, and not for claims for other provider types. Usual and customary reductions are pretty common and do occur. As long as you are not a contracted provider with the insurance company, you can bill the patient for what is not covered by the insurance policy.

If you think any discriminatory claim processing is going on, you can file a complaint with the OCI at this link:
Please also contact the WCA Help Desk at (608) 256-7023 or via email at

WI Statute 632.87(3):

632.87(3)(a)(a) No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by a licensed physician or osteopath, even if different nomenclature is used to describe the condition or complaint. Examination by or referral from a physician shall not be a condition precedent for receipt of chiropractic care under this paragraph. This paragraph does not:

632.87(3)(a)1. 1. Prohibit the application of deductibles or coinsurance provisions to chiropractic and physician charges on an equal basis.

632.87(3)(a)2. 2. Prohibit the application of cost containment or quality assurance measures to chiropractic services in a manner that is consistent with cost containment or quality assurance measures generally applicable to physician services and that is consistent with this section.

632.87(3)(b) (b) No insurer, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license, may do any of the following:

632.87(3)(b)1. 1. Restrict or terminate coverage for the treatment of a condition or a complaint by a licensed chiropractor within the scope of the chiropractor's professional license on the basis of other than an examination or evaluation by or a recommendation of a licensed chiropractor or a peer review committee that includes a licensed chiropractor.

632.87(3)(b)2. 2. Refuse to provide coverage to an individual because that individual has been treated by a chiropractor.

632.87(3)(b)3. 3. Establish underwriting standards that are more restrictive for chiropractic care than for care provided by other health care providers.

632.87(3)(b)4. 4. Exclude or restrict health care coverage of a health condition solely because the condition may be treated by a chiropractor.

632.87(3)(c) (c) An exclusion or a restriction that violates par. (b) is void in its entirety.

Ins. 3.39(5m)

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued in this state. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards. Benefit standards applicable to Medicare supplement policies and certificates with effective dates prior to June 1, 2010 remain subject to the applicable requirements contained in sub. (5).

9. Coverage in full for all usual and customary expenses for chiropractic services required by s. 632.87 (3), Stats. Issuers are not required to duplicate benefits paid by Medicare.


REVISED 2020 Medicare Physician Fee Schedule Now Available

January 9, 2020

The 2020 Medicare Physician Fee Schedule amounts were impacted by Federal legislation signed into law in late December. Because of this, our Medicare Contractor, NGS, temporarily removed the 2020 fee schedule from its website. As of January 8, the fee schedules have been updated on the NGS website.

Amounts on the updated fee schedule apply for dates of service on or after 1/1/20. Please discard previous versions of the fee schedule from the WCA which do not have the word "revised" at the top.

Click here to access the WCA 2020 Medicare Physician Fee Schedule Guide.

As a good rule of thumb, the WCA Help Desk suggests that you separate 2019 and 2020 dates of service on claims. In addition, if you are a Medicare Participating provider, you can file claims to Medicare with your full, regular fee and wait to see what comes back for the allowed amount.

In 2020, the annual Medicare Part B deductible will be $198 (an increase of $13 from 2019). Sequestration (2% reduction on covered charges) remains in effect until at least 2025 and takes place once the beneficiary has satisfied his/her deductible.

Humana Therapy Prior Authorization Requirement Does Not Apply to Chiropractors

January 6, 2020

Humana contracted providers recently received a document via fax detailing an upcoming prior authorization requirement for therapy services. The communication from Humana states that, "Effective Jan. 1, 2020 prior authorization from Optum/OrthoNet is required for all physical therapy, occupational therapy, and speech therapy providers, as well as any provider type billing one of the below CPT codes for Humana Commercial, Medicare Advantage, and dual Medicare‐Medicaid plan members." Contained within the list of impacted CPT codes are many therapy procedures which could be used within a chiropractic office, such as 97012, 97014, 97124, etc. However, the notice does state that services provided by chiropractors are excluded from Optum/OrthoNet management. More information about the Jan. 1 prior authorization requirement can be found in a Frequently Asked Questions document located here.

2020 Medicare Physician Fee Schedule UPDATE

December 30, 2019

In November, CMS released its Final Rule for the 2020 Medicare Physician Fee Schedule (MPFS). The conversion factor for 2020 was finalized at the proposed level of $36.09, a $0.05 increase over the $36.04 conversion factor for 2019 and thus impacts to individual CPT codes were expected to be very minimal (CPT 98940-98942 saw slight decreases). However, in the broader picture, on December 20, 2019 the President signed into law the Further Consolidated Appropriations Act of 2020 (FCAA) to fund the government through September 30, 2020 and avoid a government shutdown. One provision of the FCAA is that it extended the existing work geographic practice cost index (GPCI) floor under the Medicare program, set to expire on Dec. 31, 2019. The work GPCI is one component of the complex formula CMS uses to determine a final fee schedule amount for a procedure code. Each year, any of the variables can change, impacting the fee schedule. Because of this, our Medicare Contractor, NGS, has temporarily removed the 2020 fee schedule from its websiteAs of this morning (Jan. 6th) their fee schedule lookup tool is working, but we are waiting for official confirmation from NGS that the amounts are accurate.  For the time being, we have removed our annual 2020 Medicare Physician Fee Schedule guide from our website, and will update all members once the final fee schedule is released.

As a good rule of thumb, the WCA Help Desk suggests that you separate 2019 and 2020 dates of service on claims. In addition, if you are a Medicare Participating provider, you can file claims to Medicare with your full, regular fee and wait to see what comes back for the allowed amount.

In 2020, the annual Medicare Part B deductible will be $198 (an increase of $13 from 2019). Sequestration (2% reduction on covered charges) remains in effect until at least 2025 and takes place once the beneficiary has satisfied his/her deductible.

What is Cultural Competency Training and is it Required? 

August 5, 2019

Last week, an email was sent by Optum Physical Health to Participating Providers asking them to re-validate their contact information as well as attest to whether or not they had undergone "cultural competency training." Other than stating that cultural competency training was a CMS requirement, the automated email provided no additional information and required recipients to electronically sign, or attest to whether or not they had taken this training. The WCA Help Desk reached out to Optum for additional information on this communication. We also asked our health care lawyer for her expert opinion.

The groundwork was laid for cultural competency to become a requirement by Title VI of the Civil Rights Act of 1964 as well as section 1557 of the Affordable Care Act. Both apply to any providers who receive Federal financial assistance, which would include payment from Medicare and Medicaid.

Title VI of the Civil Rights Act of 1964 mandates no discrimination in Federally subsidized programs or activities. Title VI applies no matter what amount of Federal money is involved. Protected classes include, but are not limited to: Race, Color, or National Origin (this includes primary language spoken in the household). When it comes to language, Title VI Requires “Meaningful Access” to Services for those whose primary language is not English. This is where the requirement to provide translation services (which applies to DCs) stems from. For more information on the requirement to provide translation to Limited English Proficient (LEP) individuals and those who are deaf/hard of hearing click hereSection 1557 of the Affordable Care Act protects against discrimination based on sex, age and disability.

Furthermore, 42 CFR § 438.10 mandates that health plans (such as UHC/Optum) that provide services to Medicare or Medicaid recipients must make available in paper form upon request and electronic form, the following information about its network providers:

(i) The provider's name as well as any group affiliation.

(ii) Street address(es).

(iii) Telephone number(s).

(iv) Web site URL, as appropriate.

(v) Specialty, as appropriate.

(vi) Whether the provider will accept new enrollees.

(vii) The provider's cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider's office, and whether the provider has completed cultural competence training.

(viii) Whether the provider's office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment.

All of this leads one to wonder what standards apply to cultural competency training, and how does one determine if a particular training program is adequate? There are National Standards for Culturally and Linguistically Appropriate Services, or CLAS. These standards exist to inform health care providers about cultural differences in people, and how these differences impact the healthcare system.

“Published research from organizations like the Institute of Medicine, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention and more has shown that not only do people from different backgrounds have unequal access to care, but they also have disparities in health outcomes and in healthcare itself.” SOURCE: A Failure to Communicate - Caring for Patients with Limited English Proficiency – Dr. Robert Like, MD

Below are some different resources for cultural competency training. Regardless of the resource you use, you should document when you underwent the training in your compliance manual. Document when your staff takes the training as well, if applicable.

1) US Department of Health and Human Services (DHHS) National Standards for Culturally and Linguistically Appropriate Services (CLAS). Select the Administrators and Providers – Guide to Providing Effective Communication and Language Assistance Services.

2) UHC does offer online training on the UHC On Air site for participating providers including a course called, Impact of Cultural Competency and Americans with Disability Act Training. You must log in with your Optum ID to take this training.

3) The Wisconsin Department of Health Services offers various resources and training on cultural competency here:

4) U. S. National Library of Medicine - Health Services Research Information Central website. Health Literacy and Cultural Competence information including: News, Data, Tools and Statistics, Guidelines and Journals, Education, Meetings, Conferences and Webinars, Key Organizations.

***The bottom line is that while there is not a specific mandated cultural competency training class that healthcare providers must take, health plans are required by law to ask if participating providers have undergone this training on an annual basis. It is not a mandatory training nor will it remove providers from the network if not completed, it is only required for Optum to ask if it has been completed or not. Our advice at the WCA Help Desk is that cultural competency training is advisable to take from both a compliance as well as an ethical standpoint.

If you have specific questions on the Optum email that was sent to you, please contact Optum directly at 877-293-2046 or email and reference “physical health validation form.” 

Additional Resource(s):

Optum webpage on Cultural Competency:


UPDATE: Prior Authorization Requirement for PT Modalities "Delayed Temporarily" by Anthem BCBS

July 17, 2019


A July Wisconsin Provider Communications from Anthem BCBS informed Participating Providers that effective August 1, Physical Therapy, Occupational Therapy and Speech Therapy services will be subject to prior authorization review by AIM Specialty Health ® (AIM).Just a short time later, a follow up communication  dated July 16th from Anthem announced that the prior authorization requirement would be postponed until sometime after September.

The WCA reached out to Anthem BCBS to request additional information on the prior authorization review process and whether it applies to chiropractors performing physical therapy modality services, as well as what types of Anthem insurance plans it applies to.  According to Anthem BCBS, the prior authorization requirement is code specific, not provider specific. Any qualified provider performing procedures contained within the list of impacted physical therapy CPT codes will be subject to the prior authorization requirement. Examples of CPT codes subject to the requirement include: 97010, 97012, 97014, 97110, 97112, 97124, 97140. So while the prior auth requirement for PT modalities does not apply at this point in time, we are monitoring communications from Anthem and will update members as information becomes available.

Below is more information about the policy that we have learned; however, keep in mind that it is not currently in effect & is subject to change:

As far as a timeframe for the prior auth process, AIM states that if the necessary information is provided, determinations are immediate in most cases. For more information, please see the AIM FAQs here.

AIM Prior Authorization Reviews of PT Modalities will utilize the Anthem Clinical Guidelines outlined here.


Providers may submit prior authorization requests to AIM in one of several ways:

  • Access AIM’s ProviderPortalSM directly at Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity Web Portal at
  • Call the AIM Contact Center toll-free number at (800) 554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. ET.

A complete list of the CPT codes that will be subject to prior authorization review can be found at the following link:


Humana Denying Therapy Codes for Lack of Modifier
April 23, 2019

A recent policy (click here to view) implemented by Humana requiring the -96 or -97 modifier on therapy codes has started to result in denials just this month. Here is what we know so far:

  • The policy was effective 1/1/18 but Humana only recently began implementing it in early 2019
  • The policy impacts Humana Individual policies and Small Group policies
  • The policy coincides with new modifiers created by the American Medical Association effective 1/1/18 to distinguish between rehabilitative and habilitative services.
  • Modifier 96 identifies habilitative services; modifier 97 identifies rehabilitative services.
  • Habilitative services are, “Health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical therapy, occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”
  • Rehabilitative services are, “Health care services and devices that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.”
  • Simply put, rehabilitative services help patients restore functions or skills that have been lost, while habilitative services develop skills and functions that had not been developed previously.
  • Since a chiropractor most often will administer rehabilitative services, then the modifier 97 will be used for Humana Commercial plans.  Modifier 96 and 97 should not be used together on the same claim.
  • Humana plans in the individual and small group markets have separate limits on rehabilitative and habilitative services.
  • For dates of service beginning on or after January 1, 2019, providers must append modifier 96 to procedure codes for habilitative services submitted for reimbursement & modifier 97 to procedure codes for rehabilitative services submitted for reimbursement. Claims submitted without these modifiers will be denied for lack of modifier.
  • Denied claims should be appealed. Click here for Humana's appeal process.
  • These modifiers should only be used for Humana individual and small group policies. We are not advising that you append modifier -97 to therapy claims for other insurance companies at this time.

Click here to read an article from Find-A-Code on the -96 and -97 modifiers.

Anthem Denials Update

April 29, 2019 (updates are in RED )

Anthem BCBS has been keeping chiropractic offices across the state especially busy in early 2019. There have been a number of issues which have been resulting in claim denials.

1. Denials of procedure code G0283 being denied as investigational/experimental. G0283 is Electrical Stimulation, Unattended, one or more areas and is a covered code for Anthem BCBS.

  • Resolution: Denials were incorrect and an Appeal must be submitted in order to have the claim reprocess for payment.

2. Change in documentation guidelines to follow Medicare guidelines (i.e. documentation show pain, Outcome Assessments and functional improvement for all patients).

  • Resolution: We are still confirming if this applies in Wisconsin, since Anthem BCBS has different requirements by State. However, consider performing an internal audit on your Anthem BCBS documentation to ensure it is up to Medicare standards-this can only help you to show medical necessity.

3. Claim denials from Anthem BCBS due to the combination of diagnosis codes used being considered mutually exclusive.

Some of the code combinations that have been resulting in claim denials are:

S33.140D and M53.2X7

S33.5XXA and M51.26 and also M51.36

  • Resolution: The Network Relations person we have been working with at Anthem states that Anthem updated their coding guidelines in December and communicated this with contracted providers. They specifically updated some codes which are considered mutually exclusive codes. This can often occur with the S codes. If you have any claim denials due to mutually exclusive diagnosis codes, the best fix would be to remove the code causing the error, replacing with another code that would be appropriate, and resubmit the claim. According to ChiroCode, “the S33.1- codes are controversial to many. Some feel that CMT is contraindicated for this diagnosis. Click here to read a ChiroCode article about the problem. Using the “S” diagnosis codes with other codes could appear to be contradictory since the "S" codes are for injuries. For example, if used with M51.37 Other intervertebral disc degeneration, lumbosacral region, the insurance carrier may question if this was this an injury or a degenerative condition? If the patient really did satisfy BOTH, you could appeal with the documentation of both conditions. However, it might be easier to simply submit a corrected claim with an M99- as the primary diagnosis.

The ICD-10 coding guideline was updated and communicated in December 2018 (see below communication from Anthem):


System updates for 2019 – Professional

As a reminder, our claim editing software will be updated monthly throughout 2019 with the most common updates occurring in quarterly in February, May, August and November of 2019. These updates will:

  • reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
  • include updates to National Correct Coding Initiative (NCCI) edits
  • include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
  • include assistant surgeon eligibility in accordance with the policy
  • include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

Here is the reminder which was sent in February 2019 via Anthem's electronic Provider Updates:


Reminder: Review ICD-10-CM Coding Guidelines – Professional

 To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for patient encounters. Remember ICD-10-CM has two different types of excludes notes and each type has a different definition. In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes. An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section.


Hopefully you are signed up to receive the electronic updates from Anthem. If not, you can do so by visiting this link: and at the top of this page, click on “Subscribe to Email”.

4. Vague claim denials with explanation codes 066 and/or 45:

  • Resolution: Anthem has an analytics company called Cotiviti, who assists Anthem BCBS is implementing correct coding guidelines. Anthem is aware that there is an issue with the denial reasons not appearing on the EOB’s for claims that Cotiviti is examining. They state that this is a project that is being worked on and they are looking at resolution by the end of 2nd quarter (June 30th). In the meantime, if you receive any claim denials, we suggest contacting customer service and asking for clarification. Medical records may be needed.

5. E/M codes being denied when billed with an adjustment code

When billing an E/M code with an adjustment, it is necessary to append the -25 modifier to the E/M code. However, many payors will audit claims with modifiers such as 25, 51 and 59 to ensure that the code with the modifier in question meets the criteria for using that modifier.

Anthem BCBS states they are implementing this policy and that it applies to all providers.

Click here to read a recent article from Find-A-Code on E/M bundling.

We suggest appealing any denied exams. You may use our template appeal letters to help save time, click here for the template appeal letters (Note: you must be signed in with your WCA member user name and password to access).