Code 97010 is often misused and over-billed
The most common reason is that it’s difficult to establish and prove medical necessity for this service, and very often, the documentation doesn’t include appropriate rationale for using this code. Here’s what the American Chiropractic Association (ACA) has to say about code 97010:
“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 in order 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.”
For this reason, be sure that the treatment plan includes the necessary rationale for the prescribing of hot/cold packs and that you understand the guidelines for the efficacy of using this service, along with other physiotherapeutic modalities, beyond the first several visits of an episode of care.
Medicare & CPT Code 97010
Medicare considers CPT Code 97010 (hot/cold packs) a “bundled” service. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. In this instance, it means services described by 97010 are not separately billable when rendered to a Medicare patient. Instead, it’s considered a part of whatever primary service is rendered to the patient, and in chiropractic, that will be a CMT code (98940-98942). This is different than a “non-covered” service, which can be charged to the patient. A bundled service cannot be charged to the patient, as it is being reimbursed within another code’s value.
Medicare Secondary Payers & 97010
While some carriers operating as secondary to Medicare will cover 97010 when delivered in a chiropractic setting as a separate item, Medicare will not do so. 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.
Once that denial has been generated by Medicare and the automatic crossover billing to the secondary payer takes place, the secondary payer may accidentally pay the 97010. You would 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.
Thank you so much for this class! It has brought clarity and guidance to me (as well as created many more questions, but all a huge positive to me and our staff).