Saturday, 17 December 2016

Procedure code 97012

97012 Application of a modality to one or more areas; traction, mechanical

97012 Mechanical Traction

• A recent decision by the US District Court of the District of Rhode Island may have significant implications for doctors of chiropractic (DCs) across the country who bill for mechanical traction. 

In 2009, Blue Cross Blue Shield Rhode Island (BCBS RI) sued two providers in state court for allegedly fraudulently billing intersegmental tractionas mechanical traction, CPT code 97012. 

Attorneys for the providers were able to successfully move the case to federal court where the judge in the case, Senior Judge Ronald R. Lagueux, found that the fraud claims were "completely preempted" by the Employee Retirement Income Security Act (ERISA). 

At the conclusion of the resulting bench trial, Judge Lagueux found that the services were correctly billed by the providers as mechanical traction and rejected BCBS RI's findings of fraudulent billing, stating that the plaintiffs "did no wrong." 

The case was argued on behalf of the plaintiffs by D. Brian Hufford of Pomerantz, Grossman, Hufford, Dahlstrom & Gross, LLP (Pomerantz), the same firm representing ACA and other plaintiffs in class action suits against United Healthcare/Optum and Cigna and ASHN

• While this lawsuit was not the result of any action by ACA, it has been ACA's policy for over a decade that “roller table type traction normally meets the requirement of autotraction, the use of the body's own weight to create the force" and therefore is properly coded, as the doctors in question had and the court supported, with 97012. 

While doctors of chiropractic should always verify coverage to determine each payer's specific reimbursement policy, this decision may have an impact on providers who have had reimbursement for traction recouped.

Understanding Time Rules

• CMS – Special Rules

– Less than 8 Minutes

• Can’t Bill but Save the Time…

– Bundling Services of Same Time

• Lower Value Bundles to Higher Value

– Bundling Services of Different Time

• Lower Time Bundles to Higher Time

Practical Exercise – CMS – Result

• 97012 – 1 Unit

• 97110 – 1 Unit – Since there was not enough total time (in timebased services) to justify 2 total time-based units, the lower time service bundles into the higher time service. As 97110 was the service with higher time, 97140 bundles into 97110.

CPT 97012

CPT Description: Supervised Modalities Traction, mechanical

Reimbursement Policy: Payment is allowed for one clinically indicated and medically necessary modality or procedure from this list per date of service. Reimbursement of modalities and procedures is subject to the subscriber certificate.

Traction - 97012 Application of a modality to one or more areas; traction, mechanical

Traction is used to treat a variety of musculoskeletal disorders of the neck and back, including muscle spasm, radiculopathy, discogenic pain and degenerative changes. 

Although most insurance plans do cover traction, clinicians can increase the likelihood of reimbursement by ensuring that the patient’s medical record contain items such as a description of the condition(s) that justify medical necessity for a traction device. 

Many payors request that a Letter of Medical Necessity be completed by the treating physician.

The following documentation is recommended:

 Diagnosis that describes the patient’s condition(s) (examples
 include: radiculopathy, neck/back pain,  muscle spasm);
 Evidence of treatments that have been attempted and failed  (i.e., medications, physical therapy);
 Evidence that treatment with supine traction of at least 20  pounds has been beneficial;
 Follow-up visit notes, documenting patient benefit from the  device (i.e., improved range of motion, decreased pain,  decreased medication or improved sleeping/ working  patterns).

97012, Mechanical Traction

Under WAC 246-808-540, a chiropractor must use codes and/or descriptions of services that accurately describe the professional services rendered.

Like other professions, chiropractors use the Current Procedural Terminology (CPT) codes maintained by the American Medical Association. Under the heading of the instructions for “Use of the CPT Code Book,” it specifically states to select the name of the procedure or service that accurately identifies the service performed. This article is based upon the ACA’s Chiropractic Coding Solutions Manual and the Manual of Chiropractic Code.

Mechanical Traction:

CPT 97012 Mechanical traction is described as force used to create a degree of tension of soft tissues and/or to allow for a separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration of time, and angle of the pull (degrees) using mechanical means. 

Used in describing cervical and pelvic traction that are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body’s own weight to create the force). A common question is whether a roller table type of traction meets the above-noted requirements. According to the ACA’s interpretation, table type traction would normally meet the requirements of autotraction.

It should also be noted that manual traction, using one's hands or a towel to perform the traction, is identified under manual therapy CPT 97140 and, presumably, would not be recognized under mechanical traction.

97012—Mechanical traction. This includes both cervical and lumbar-pelvic mechanical traction. This CPT code does not include over-the-door cervical traction or other noncovered forms of traction. Specific indications for mechanical traction include cervical or lumbar radiculopathy, lumbago, sciatica, disc herniation, and other back disorders.

How Do You Code for Spinal Decompression?

Q: I have a new spinal decompression unit and have been told I can bill for heat, therapeutic activities, electrical stimulation, joint mobilization and exercise when I use it. That seems odd to me, since it is a traction device. Is there a code for using this machine?

A: Spinal decompression machines - vertebral axial decompression - have become quite popular and appear to be offering some positive responses to disc patients, at least empirically. But for insurance billing purposes, spinal decompression does not have a specific CPT code to describe the services of spinal decompression. In the HCPCS coding system, there is a code to describe "vertebral axial decompression," and that code is S9090. 

The code is noted as "per session" and indicates the amount of time or number of regions for which the unit is used, which is not relevant to its billing. In other words, it is billed once per treatment session. Based on the code that best describes the service, S9090 certainly fits that category. I recently received information from several California providers that they were getting reimbursed $140 a session for S9090 from Blue Cross. 

I am concerned that these payments will later be reviewed and further payments for the code will not be made. The code S9090 has been around for a few years and, when initially introduced, was being paid by many Blue Cross and Blue Shield plans. However, payments did not persist and were eventually denied.

These denials were based on the Medicare (CMS) ruling that spinal decompression had insufficient data to support the benefits of its use. Manufacturers of the devices use as a sales tool the fact that spinal decompression units are FDA-approved, which they are. However, FDA approval does not necessarily  equate to efficacy of use and the service may still be denied as not reasonable or necessary.

I have researched several insurance carriers and have found that AmeriHealth, Blue Cross and Blue Shield, CIGNA Health Care, UNICARE, United Healthcare, Regence and Humana all note the billing for a spinal decompression unit should be with S9090. Medicare requires the use of 97799; "unlisted physical medicine/rehabilitation service," with modifier GY and the explanation in block 19 of the 1500 form to state "VAV-D."

While the code S9090 is the one stated by most carriers to use, they also may have a policy that it is not to be reimbursed, noting the CMS stance on the service. This is quite the "catch-22" - you can use it, but we are not paying you for it. There is a policy from United Health and ACN Group that allows the provider to choose between S9090 and the code 97012. (97012 is the CPT code for mechanical traction.) While they will not pay for S9090, they will pay for 97012. 

The downside is the fee for 97012 is typically substantially less than what most providers bill for S9090. That ratio of billing for 97012 would be 15 percent to 25 percent of what is normally charged for S9090. One may choose to not use 97012 and use S9090, have the claim denied, and consequently bill the patient directly for spinal decompression. This assumes that the provider is not a member of the plan, or is allowed to bill the insured (patient) for services not covered or denied under the plan benefit.

Spinal decompression appears to show great promise. I have some personal experience, with positive results. But while it is called "spinal decompression," it is, in my opinion, a form of mechanical traction. In that sense, it is still a "mouse trap," albeit a better one. 

Therefore, considering the lack of reimbursement for S9090, the future may hold more consistent reimbursement from 97012. The drawback is the high cost of the decompression devices and the ability of the provider to utilize them and generate enough reimbursement to justify cost.

As far as using codes for electrical stimulation, joint mobilization, therapeutic exercise or therapeutic activities, those codes would be inappropriate if used to code spinal decompression. Those services are individual modalities or procedures that are distinct services, which would require separate performance from the spinal decompression. 

Unless that is the case, do not bill for those services, as they are not included as part of spinal decompression and they do not describe spinal decompression.


Respondent’s Position Summary: “We received the first CMS1500 form on 4/14/15. Dates of Service were 10/20/14-12/31-14 which was denied for timely filing.

Dates of service 1/5/15-3/10/15 appear to need partial reimbursement… CPT code 98941 should have been reimbursed however, CPT code 97012, would have been denied due to lack of preauthorization. Our records reflect Date of Service 3/2/15 was processed correctly… Our records further reflect Date of Service 4/14/15 was processed correctly…

It is our position denial should be maintained for dates of service 10/13/14-12/31/14, due to timely filing. We also feel denial would apply to all charges incurred for CPT 97012, due to lack of preauthorization, as required by TAC §134.600(p)(5).”

Response Submitted by: Claims Administrative Services, Inc.
Disputed Services - Evaluation & Management, established patient (99203-25) Radiologic Examination (72080) Chiropractic Manipulation (98941) Physical Therapy (97012)


1. What are the services in dispute?
2. Did the requestor waive the right to medical fee dispute resolution for dates of service October 13, 2014 through October 21, 2014?
3. What is the timely filing deadline applicable to the medical bills for the services in dispute?
4. Did the requestor forfeit the right to reimbursement for the services in dispute?
5. Does a preauthorization issue exist for CPT code 97012 on dates of service January 5, 7, 12, and 15, 2015?
6. Is the insurance carrier’s denial of payment based on preauthorization for CPT code 97012 for dates of service March 2 and 10, 2015; and April 14, 2015 supported?
7. What is the maximum allowable reimbursement for the disputed services?
8. Is the requestor entitled to additional reimbursement?

The insurance carrier argued in their position statement that CPT code 97012 for dates of service January 5, 7, 12, and 15, 2015 “would have been denied due to lack of preauthorization.” 28 Texas Administrative Code §133.307(d)(2)(F) states, in relevant part, “The response shall address only those denial reasons presented to the requestor prior to the date the request for MFDR was filed with the division and the other party. Any new denial reasons or defenses raised shall not be considered in the review…”

Review of the submitted documentation finds that CPT code 97012 for these dates of service was not denied  for lack of preauthorization prior to the date the request for MFDR was filed with the division. Therefore, theDivision finds that a preauthorization issue does not exist for this service on the dates of service in question.

“PERCERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT.” 28 Texas Administrative Code §134.600(p)(5) requires preauthorization of physical and occupational therapy services, which includes those services listed in the Healthcare Common Procedure Coding System (HCPCS) at the following levels:

(A) Level I code range for Physical Medicine and Rehabilitation, but limited to:

(i) Modalities, both supervised and constant attendance;
(ii) Therapeutic procedures, excluding work hardening and work conditioning;
(iii) Orthotics/Prosthetics Management;
(iv) Other procedures, limited to the unlisted physical medicine and rehabilitation procedure code

(B) Level II temporary code(s) for physical and occupational therapy services provided in a home setting;

(C) except for the first six visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediately following:

(i) the date of injury; or
(ii) a surgical intervention previously preauthorized by the insurance carrier; Submitted documentation does not support that the disputed services were performed within the first six weeks following the date of injury or a surgical intervention. For this reason, CPT code 97012 required preauthorization. The insurance carrier’s denial reason for these dates of service is supported. 

Additional reimbursement cannot be recommended for procedure code 97012 for these dates of service. To determine the MAR for professional services, system participants shall apply the Medicare payment policies with minimal modifications.

(1) For service categories of Evaluation & Management, General Medicine, Physical Medicine and Rehabilitation, Radiology, Pathology, Anesthesia, and Surgery when performed in an office setting, the established conversion factor to be applied is $52.83…

(2) The conversion factors listed in paragraph (1) of this subsection shall be the conversion factors for calendar year 2008. Subsequent year's conversion factors shall be determined by applying the annual percentage adjustment of the Medicare Economic Index (MEI) to the previous year's conversion factors, and shall be effective January 1st of the new calendar year…

The Medicare fee is the sum of the geographically adjusted work, practice expense and malpractice values multiplied by the conversion factor. The MAR is calculated by substituting the Division conversion factor. The Division conversion factor for 2015 is $56.20.

For CPT code 97012 on January 5, 2015, the relative value (RVU) for work of 0.25 multiplied by the geographic practice cost index (GPCI) for work of 1.000 is 0.250000. The practice expense (PE) RVU of 0.19 multiplied by the PE GPCI of 0.920 is 0.174800. The malpractice (MP) RVU of 0.01 multiplied by the MP GPCI of 0.822 is 0.008220. The sum of 0.433020 is multiplied by the Division conversion factor of $56.20 for a MAR of $24.34.

For CPT code 97012 on January 7, 2015, the RVU for work of 0.25 multiplied by the GPCI for work of 1.000 is 0.250000. The PE RVU of 0.19 multiplied by the PE GPCI of 0.920 is 0.174800. The MP RVU of 0.01 multiplied by the MP GPCI of 0.822 is 0.008220. The sum of 0.433020 is multiplied by the Division conversion factor of $56.20 for a MAR of $24.34.

For CPT code 97012 on January 12, 2015, the RVU for work of 0.25 multiplied by the GPCI for work of 1.000 is  0.250000. The PE RVU of 0.19 multiplied by the PE GPCI of 0.920 is 0.174800. 

The MP RVU of 0.01 multiplied by the MP GPCI of 0.822 is 0.008220. The sum of 0.433020 is multiplied by the Division conversion factor of $56.20 for a MAR of $24.34.

For CPT code 97012 on January 15, 2015, the RVU for work of 0.25 multiplied by the GPCI for work of 1.000 is 0.250000. The PE RVU of 0.19 multiplied by the PE GPCI of 0.920 is 0.174800. 

The MP RVU of 0.01 multiplied by the MP GPCI of 0.822 is 0.008220. The sum of 0.433020 is multiplied by the Division conversion factor of $56.20 for a MAR of $24.34.

The total MAR for the disputed services is $97.36. The requestor is seeking $80.00 for these services on the dates in question. The insurance carrier paid $0.00. An additional reimbursement of $80.00 is recommended. Conclusion

CODE 97012

“Code 97140, Manual therapy techniques {e.g., mobilization/manipulation, manual lymphatic drainage, manual tract}, one or more regions, each 15 minutes, is a therapeutic procedure which consists of, but is not limited to, joint mobilization and manipulation, manual traction, soft tissue mobilization and manipulation, and manual lymphatic drainage. 

As the code descriptor states, in a manual technique, provider use their hand to administer these techniques. Therefore, code 97140 describes hands-on therapy techniques requiring one-on-one patient contact by the provider.

Code 97012, Application of modality to one or more areas; traction, mechanical, would be reported 
for the mechanical traction to the cervical spine.” 97012 and 97140 are two different type of services---- mechanical versus manual versus mechanical and not one-on-one with the patient versus one-on-one with the patient. Based on the National Correct Coding Initiative Edits, code 97012 is not listed as a component code to 97140. Therefore, if 97012 is submitted with 97140—both reimburse separately.

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