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Wednesday, July 22, 2015   (0 Comments)
Posted by: Sheri Ryan
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The Association of New Jersey Chiropractors (“ANJC”), New Jersey’s largest chiropractic professional society consisting of over 1,900 licensed chiropractors, is pleased to announce that it has reached an accord with Aetna Insurance Company concerning its nation-wide reimbursement of chiropractors for performing manual therapy on patients and billed under CPT 97140.   

By way of background, in March of 2013, Aetna implemented a national reimbursement policy which bundled CPT 97140 (manual therapy) into a chiropractic manipulative adjustment (“CMT”) if performed on the same day.  Under this prepayment review policy, any submission of CPT 97140 on the same date as a CMT would require the doctor to submit patient records with their claim submission to establish that the manual therapy was provided to a separate and distinct anatomical structure from the CMT.

In light of this reimbursement policy that the ANJC deemed improper and, in its opinion, violative of federal healthcare laws, the ANJC filed a declaratory judgment lawsuit in the U.S. District Court for the District of New Jersey in 2013.  The ANJC and high-level Aetna officials thereafter met prior to Aetna filing an answer to the complaint and, after a period of several months of discussions, reached an amicable settlement in the matter.

The specific details of this settlement are subject to confidentiality provisions, but the non-confidential parameters of the agreement are as follows:

  1. Extra-Spinal Diagnoses:  Aetna and the ANJC have agreed upon a list of extra-spinal ICD-9 diagnosis codes that will be automated in Aetna’s claim payment engines to accept the -59 modifier and pay the claim without the need for pre-payment review and patient record submission.  The ICD diagnoses not on this agreed upon list will still be subject to pre-payment review. 
  2. Spinal Diagnoses:  Aetna and the ANJC have agreed upon modification of Aetna’s reimbursement policy concerning payment for CMT and 97140 in the spinal regions by amending the existing policy language, which previously did not permit separate reimbursement for 97140 if the therapy was provided to any soft tissue with its origin or insertion in the CMT region.  The new policy language now expressly recognizes that 97140 can be provided to soft tissues in different anatomic sites, even if these soft tissues span multiple body areas, including the region of the CMT.  Manual therapy will be separately reimbursed when properly diagnosed, documented, and billed with the -59 modifier.  Spinal diagnoses will still be required to undergo pre-payment record review to ensure proper documentation of the 97140 in accordance with the revised policy.
  3. Notification to Chiropractors:  Aetna has agreed to post the list of ICD-9 extra-spinal diagnoses that will be automated as well as the revised spinal diagnoses reimbursement language clearly and prominently on its public website as well as in its newsletter to participating providers so that full disclosure and transparency of these revisions are provided to chiropractors.
  4. ICD-10:  Aetna and the ANJC have agreed to work in good faith to address ICD-10 diagnosis codes if and when they become effective (presently scheduled for 10/1/15) with the intent to further automate 97140 claim reimbursement without the need for pre-payment review of records.
  5. Education to Membership: The ANJC has pledged to create and disseminate a comprehensive education program to chiropractors on these new reimbursement policies, proper billing, coding and documentation for 97140, and how to properly perform and bill for such services in a compliant manner.

The ANJC would like to thank Aetna, its officials and legal counsel for their willingness to meet and resolve this matter at the inception of the dispute to discuss the issues in a professional manner without resorting to protracted costly and uncertain litigation.  The ANJC and Aetna have further agreed that, if future issues arise concerning CPT 97140, they will first discuss the issues and attempt to resolve them amicably prior to instituting litigation, which is a benefit for all involved.

This is a resounding victory for chiropractors nationwide as this revised 97140 reimbursement policy will not only affect New Jersey chiropractors, but, rather, chiropractors across the nation.  As a result of this resolution, many extra-spinal conditions that are treated with manual therapy on the same day as a CMT will be adjudicated without the time consuming and costly requirement to submit patient record documentation on prepayment review.  Further, the new spinal reimbursement policy language should result in 97140 being paid in conjunction with a CMT when performed on tissues that span the spinal region of the CMT that are properly documented in accordance with the policy language. 

The ANJC will be providing a schedule of seminars and webinars that will provide more specifics on the ICD-9 diagnoses codes, analysis of the new reimbursement policy, and detailed instruction on how to treat, bill and document in a compliant manner to obtain reimbursement for CPT 97140 under Aetna plans.   


By: Jeffrey Randolph, Esq.

ANJC Legal Counsel



Matt Minnella

Director of Insurance

Association of New Jersey Chiropractors

Office: 908.722.5678

Fax: 908.722.5677




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