HNS Policy 

Services reported on claims submitted though HNS must reflect the most appropriate ICD, CPT, and/or HCPCS codes.

 

Codes must be appended by appropriate modifiers, when applicable.

 

Providers are responsible for ensuring the number of units reported for each service is accurate and supported by information in the health care record.

  

 

 

ICD Codes

ALL diagnoses must be recorded in the healthcare record including primary, secondary, and any additional diagnoses.


All ICD codes reported to a HNS contracted payor must be properly documented, consistent with the patient’s chief complaint/clinical findings and treatment plan, and must support the necessity of services provided.


ICD codes reported on insurance claims must be consistent with HNS and HNS payor policies, the policies of applicable licensing boards, as well as state and federal laws.


Providers must use the most accurate and appropriate ICD code for services reported on an insurance claim.  


The ICD-10 section of the HNS Website has helpful information regarding ICD-10 coding.

 

 

 

CPT Codes

Providers must assure the CPT codes reported on the insurance claim accurately reflect the services provided, are the most appropriate CPTs for the services provided, and that those services are properly documented in the healthcare record. 


Only CPT codes that reflect services that are medically necessary, consistent with the patient’s chief complaint/clinical findings, diagnoses, and treatment plan should be reported on claims filed through HNS.


CPT codes reported on insurance claims filed through HNS must be consistent with HNS and HNS Payor Policies, the policies of applicable licensing boards, as well as state and federal laws.


Providers must use the most accurate and appropriate CPT code for services reported on an insurance claim.

 

 

 

HCPCS

HNS providers must report the most appropriate HCPCS code on all insurance claims filed through HNS.


HCPCS codes should only be billed to a HNS contracted payor if the service is medically necessary, consistent with the patient’s chief complaint/clinical findings, diagnoses, and treatment plan.  (Exception: Maintenance care. When maintenance care is covered, it must be billed using S8990)


HCPCS codes can only be billed to a HNS contracted payor if the service is consistent with HNS and HNS Payor Policies, the policies of applicable state licensing boards, and state and federal laws.


All DME provided must be documented in the healthcare record.


Documentation in the healthcare record must include the specific DME recommended, the date the DME was ordered, and the date the DME was delivered to the patient. Proof of purchase of the DME, unless rented, must be available upon request if requested by a contracted payor or HNS.  Rental agreements for DME must be available upon request if requested by a contracted payor or HNS. 


Documentation in the healthcare record should include all instructions given to the patient regarding the use of any DME.  If written standards are maintained for DME that include specific instructions, reference to the written standard is acceptable.


If written standards for DME are utilized, they should include the following statements:

 

  • The need for any DME billed to a payor is consistent with the patient’s chief complaint/clinical findings, diagnoses, and treatment plan.  

  • The patient’s healthcare record clearly establishes the medical necessity for any DME billed to the payor.

 

For all CPT and HCPCS codes reported on a healthcare claim, providers must assure the accuracy of the number of units reported.  The number of units reported must be supported by appropriate documentation in the healthcare record.

 

 

 

Modifiers

When applicable, providers must use appropriate modifiers when reporting and billing chiropractic services to a HNS contracted payor. 


The use and/or need for the modifier must be supported by appropriate documentation in the healthcare record.


NOTE: At this time, HNS contracted payors cannot accept more than one modifier per code; accordingly, HNS providers should only report one modifier per service line. 

 

 

 

Coding - General Information:

Only valid ICD, CPT, and HCPCS codes should be reported on insurance claims submitted through HNS.   


Many HCPCS codes are not covered by HNS contracted payors. In addition to verifying benefits, please check the applicable payor corporate medical policy and/or contact your HNS Service Representative if you have questions or need assistance.

 

 

 

Modifier - General Information:

Modifier – 59 Distinct Procedural Service

Indicates that a procedure or service is distinct or separate from other services performed on the same day 


Payors require the use of modifier 59 with certain codes and without this modifier the claim will likely not be correctly adjudicated.  For this reason, it is important to understand which codes require modifier 59.
 


Providers should append CPT 98943 (extraspinal) with a 59 modifier when reporting it together with a spinal manipulation code.


HNS providers must use modifier 59 for each of the following CPT codes when these codes are billed with E/M and/or CMT codes.

  • 97112

  • 97124

  • 97140

  • 95831

  • 95832

  • 95833

  • 95834

  • 97760


NOTE:  If you perform a time based service together with an E/M and/or CMT service that must be appended by modifier 59, and you also provide the service for less than 15 minutes, you must append the code with the modifier 59 not with a modifier 52.  However, your documentation must reflect the actual time you provided the service (i.e.  10 minutes).

 

 

Modifier – 25  Significant, Separately Identifiable E/M Service

NOTE:  This modifier is only to be used with E/M codes and should not be added to any other code.


If you are billing an E/M service in addition to a chiropractic manipulation code (98940, 98941, 98942, 98943) for the same patient on the same date of service, you should append the E/M code with the modifier 25.
 

 

 

Modifier – 52  Reduced Services

If you are reporting a time-based procedure and you provide the service for less than the full unit (15 minutes) but at least 8 minutes, in general, you should append this code with a modifier 52.


Exception:  If the service is reported with CMT or E/M service and requires the use of modifier 59 to prevent bundling, then always append with the modifier 59. However, your documentation must reflect the actual time you provided the service (i.e. 10 minutes).

 

 

Modifier – 26 Professional Component

This modifier indicates the provider is reporting the professional component ONLY for a service.  This code would be appropriately reported by a Chiropractic Radiologist who did not actually see the patient but interpreted the study. If the study is performed in your office and you interpreted the study, the CPT code for the study should not be appended with any modifier. 


NOTE:  The pre-service work included in the CMT codes includes imaging review. The review of imaging studies included in the CMT service applies regardless of whether the studies were performed in your office or if the patient brings films to you that were taken elsewhere.