The use of, and billing of hot and cold packs in the chiropractic setting with Medicare patients is quite often misunderstood. More often than not it is overbilled, because it is difficult to appropriately establish appropriate rationale to prove medical necessity for this to be separately billed in the office. The American Chiropractic Association (ACA) has published this guidance for the proper use of the service:
“It is the position of the American Chiropractic Association that the work of hot/cold packs as described by CPT code 97010 is not included in the CMT codes 98940-43 in instances when moist heat or cryotherapy is medically necessary to achieve a specific physiological effect that is thought to be beneficial to the patient. Indications for the application of moist heat include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation and increase in lymph flow to the area. Indications for the application of cryotherapy include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation and increase of lymph flow to the area.”
It is imperative that you understand the guidelines for the efficacy of using this service along with other modalities beyond the first several visits of care, and that any written treatment plan includes the necessary rationale for prescribing hot/cold packs.
97010 (hot/cold packs) is considered a ‘bundled’ service by Medicare. What this means for chiropractors is that the reimbursement for the code 97010 is built into or grouped with the reimbursement for another code. When a code is considered bundled this means it is not a separately payable Medicare billing code. When Medicare is the primary payer and you submit 97010-GY along with covered CMT codes 98940-98942, the 97010 service will be denied with the remark code M15: Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
In the case of chiropractic treatment, the primary service rendered is CMT codes 98940-98942, and the hot/cold pack is considered a part of that primary service. Therefore, it is very important to remember that because the code is bundled it is different than a ‘non-covered’ or ‘excluded’ service, which must be charged o the patient. A bundled service can never be separately charged to the patient, as it is being reimbursed within another code’s value, such as the CMT.
97010 & Medicare Secondary Payers
It is important to be aware of how billing 97010 is impacted if Medicare is the primary or secondary payor. Some carriers who are a secondary payor to Medicare cover 97010 as a separate service when delivered in a chiropractic setting, but Medicare will not do so.
The CPT code 97010 will be denied with the remark code M15: Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed, when Medicare is the primary payer and you submit 97010-GY with covered CMT codes 98940-98942.
Following the submission of a claim that includes both a 97010, and a 98940-98942 to Medicare, a denial will be generated by Medicare and the automatic crossover billing to the secondary payer takes place. When this occurs the secondary payer may accidentally pay the 97010. In the event you discover that you were accidentally paid, or if you are audited you will be expected to correct the error and refund any money paid by the secondary payer and you still may not seek payment from the patient for this bundled service.