Aetna Agrees to Allow CMT + 97140

For our chiropractic clients, Aetna instituted a policy effective March 1, 2013 stating that manual therapy (CPT code 97140) would not be denied for separate payment when billed with CMT 98940-98943.  It also stated that modifiers 25 and 59 would NOT override to allow reimbursement.

However, Aetna has since reversed this policy IF proper documentation showing that the 97140 manual therapy was done to a different area than the CMT and was medically necessary.  IN ADDITION, per recent settlement with the New Jersey Chiropractic Association, Aetna will PAY for claims with extra-spinal diagnosis codes.

• To see the terms of the settlement, AETNA-CPT-97140-Settlement-Release.pdf
• To see the list of allowed ICD9 codes, Aetna-97140-Allowed-ICD-9-Codes.pdf .
  • PROVIDERS MUST ENSURE TO USE THE ICD10 EQUIVALENT OF THE ALLOWED ICD9 CODES FOR DATES OF SERVICE ON OR AFTER October 1, 2015.

If your claim does NOT have extra-spinal diagnosis codes as allowed by Aetna, Aetna is now indicating that INITIAL claims for a patient may be submitted with proper documentation for review so that there is no need for denial.

If Your Claim is Denied:

• For our chiropractic clients, if your claim is denied, we have created an online PDF appeal template letter which you can use.  You may complete the letter and send to Aetna with the EOB you have received.
• If you want us sending the letter, together with a copy of the claim and the EOB, please advise via email.
• To see the sample template you can use, see Aetna 97140 Denied Appeal Template.pdf .
• INSTRUCTIONS FOR USE OF THIS TEMPLATE:
  • Enter your Practice Name, Practice Street Address, Practice City, State, Zip, and Practice Phone in the fields at the top.
  • Most other fields are self-explanatory.  But at the bottom of the second paragraph after the word because you should insert in that field a statement of medical necessity showing functional improvement achieved, or attempting to be achieved, related to original goals in the treatment plan and diagnosis of condition in separate region.  ENSURE YOU DO NOT TYPE PAST THE ONE LINE ALLOWED.

If You Want To Submit Documentation With the Initial Claim for a Patient:

• If you want to submit documentation with the initial claim you submit for a patient, the ACA has designed a template for use with appeals.  However, you can modify this template to indicate it is for the initial claim for a patient.
• See:  Aetna ACA 97140 Template.pdf .

NOTE THAT SUBMITTING DOCUMENTATION WITH THE APPEAL LETTER TO AETNA DOES NOT GUARANTEE PAYMENT OF THE MANUAL THERAPY CODE.  However, the better your documentation is showing that the manual therapy was done to a different region than the CMT, the more likely Aetna will be with paying for the manual therapy.  Should Aetna deny after you provide the documentation, you should call Aetna to appeal the denial.  If necessary, it is recommended that you speak to a supervisor so they will reverse the denial.