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Chiropractic vs Physical Therapy Insurance Billing

A patient receiving treatment from a chiropractor.

When looking at chiropractic vs physical therapy billing, it’s easy to get the two confused. Both disciplines carry some similarities but are ultimately completely different specialties. It is important to distinguish between them, especially when it comes time to bill for services. Utilizing an EDI/clearinghouse partner that is familiar with both categories of claims can be a great resource for providers looking to improve billing/revenue. In the meantime, however, let’s find out what makes these two so different when it comes to billing and claim management.  

Likelihood of Coverage 

While the two specialties carry great differences, there are a few key elements they share. They both work one-on-one with patients to treat similar maladies and with similar methodologies. However when it comes to insurance billing and claim management, these two practice types are very different.  

Whereas physical therapists usually work out of hospitals, outpatient centers, and school, chiropractors are limited to private practices, and they’re less likely to be covered. Let’s dive into why this is the case.  

Physical Therapy:  

Under the Affordable Care Act (ACA), law requires physical therapy to be covered by ACA marketplace health insurance.  

According to the American Physical Therapy Association, federally qualified HMOs are required to have physical therapy within their benefits plan. The level of coverage will differ on an individual plan-to-plan basis.  

For providers of physical therapy, this is good news and means that your patients are likely to have coverage for services as long as they are insured.  

PTs that wish to accept insurance need to get credentialed with each insurance provider they wish to have a relationship with. Without completing this step, you will not be able to receive payments for your claims directly from payers.  

Chiropractic Care:  

Coverage for chiropractic care is not as expansive as physical therapy. When looking a chiropractic vs physical therapy services, chiropractors are usually covered for at least part of the cost. It is much less likely that an entire chiropractic bill would be covered in full by an insurance payer.  

Some common restrictions placed on coverage include payments for treatments that are not medically necessary (meaning a patient would need a referral), caps for how frequently a patient can visit, and a stop in coverage if recovery has plateaued.  

Unlike PT coverage, employer-sponsored policies are not required to cover chiropractic vs physical therapy services. Providers should focus on credentialing with payers that cover their services.   

Billing Errors for Chiropractic and Physical Therapy 

Coding Errors 

One of the most common billing issues that all providers face is the accuracy of their coding and claims process. The most frequent cause for a denied claim is that it was coded incorrectly. A quality EDI/clearinghouse solution can help providers minimize coding mistakes and perfect the accuracy of their claims to optimize them for approval.  

Resubmittals  

When a claim is denied, it must be resubmitted within a certain time frame to be reconsidered for approval. This means that providers need to address the issues that caused the denial and turn it back into the payer for their best hopes of getting paid for that claim. Regardless of whether it is a chiropractic vs physical therapy provider, both commonly struggle to meet these deadlines.  

Overcoding  

Overcoding happens when a provider codes a claim to reflect that the patient received more complex treatment than they actually experienced. This leads to an increased reimbursement from a payer and raises a red flag on their end.  

Omitted Information  

Another common reason for denials is that necessary information was omitted, or left out, of the claim. Claims need to be fully completed prior to submission or it will most likely result in a denial. Omitted information might include a patient’s information, their group ID, or an incomplete charge.  

A patient receiving care from a physical therapist. 
Physical therapy treats a more expansive range of maladies and, more enmeshed with traditional medical treatment, is more likely to be covered by a patient’s insurance. 

Common CPT Codes for Physical Therapists 

  • 97110: Therapeutic Exercise 
  • 97112: Neuromuscular Re-education 
  • 97116: Gait Training 
  • 97140: Manual Therapy 
  • 97150: Group Therapy 
  • 97530: Therapeutic Activities 
  • 97535: Self-Care/Home Management Training 
  • 97750: Physical Performance Test or Measurement 
  • 97761: Prosthetic Training 
  • 292**, 295**: Strapping 
  • 90901, 90911: Biofeedback 

Top CPT Codes for Chiropractors 

  • CPT Code 99203 – Initial Exam 
  • CPT Code 98940 – Chiropractic manipulative treatment (CMT); spinal, 1-2 regions 
  • CPT Code 97110 – Therapeutic Exercise 
  • CPT Code 98940 Chiropractic manipulative treatment (CMT); Spinal, 1-2 regions 
  • CPT Code 98941 Chiropractic manipulative treatment (CMT); Spinal, 3-4 regions 
  • CPT Code 98942 Chiropractic manipulative treatment (CMT); Spinal, 5 regions 
  • CPT Code 98943 Chiropractic manipulative treatment (CMT); Extraspinal, 1 or more regions

I would like to take a moment and express my gratitude. Our transition to Apex has been the smoothest transition I have ever been involved with. From the moment we called Apex to request information regarding your services, we have had overwhelming support. I could not be more pleased with our decision to choose your company to do business with.

Tracy Karle, Billing Manager

The Benefits of the Apex EDI Electronic Clearinghouse  

Despite their differences in practice methods, both rely on practice management technology, and both can bill insurance companies to generate revenue. As such, chiropractic and physical therapy clinics should consider onboarding clearinghouse solutions like Apex EDI to simplify their claim processing, especially with the variances in insurance coverage. To learn more about how a clearinghouse can support your chiropractic or physical therapy office or specialized EHR, schedule a demo today.  

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Apex EDI, Inc.
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Orem, Utah 84097
Support: (800) 840-9152
Sales: (801) 383-0388
Fax #: (801) 642-0333
 
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