What the statutes mean

Because there are thousands of different health care problems and related services, the state believes it is in the best interests of consumers if all health care providers are required to bill their services in a standardized manner. These rules require a chiropractor to use a CMS 1500 form when submitting a claim to an insurance company or directly to a patient.

It is important to note that there is no exception for “cash patients”. Every time a patient receives a bill for their services, the law requires it to be on a CMS 1500 form. This ensures that a consistent methodology, based on common terminology, is used with all health care professionals.

In addition to the required use of CMS 1500 forms, the only coding systems an insurer may require a chiropractor to use are the following:

• HCPCS codes.
• ICD-9-CM codes.

An insurer may not require a chiropractor to use any other verbal descriptor with a code or to furnish additional information with the initial submission of a CMS-1500 form except under the following circumstances:

• When the procedure code used describes a treatment or service which is not otherwise classified.
• When the procedure code is followed by the CPT-4 modifiers. A chiropractor using CPT modifiers may use item 19 of the CMS-1500 form to explain the modifier.
• When the chiropractor has signed a contract with a managed care company or insurer and the contract requires additional information to be sent with the claim.

A chiropractor may use item 19 of the CMS-1500 form to indicate that the form is an amended version of a previously submitted claim by inserting the word “amended” in the space provided.

In completing the CMS-1500 form, the doctor or staff person filing the claim must do all of the following:

• In item 17a, use the unique physician identifier number assigned by CMS or, if the chiropractor does not have such a number, the chiropractor’s taxpayer identification number assigned by the U.S. internal revenue service.

• In item 33, use both of the following:
– The name and address of the payee.
– The unique physician identifier number assigned by CMS to the chiropractor who performed the procedure or ordered the service or, if the chiropractor does not have such a number, the chiropractor’s taxpayer identification number assigned by the U.S. internal revenue service.

Practical advice

The CPT book is updated annually by the American Medical Association. Because many codes change each year it is important for chiropractors to purchase a new book each year. The Wisconsin Chiropractic Association does not recommend buying “chiropractic coding books’ because doing so may subject a chiropractor to serious risks.

A chiropractor is responsible for understanding the complete health care history of their patient. This often means obtaining health care records from other health care providers. If a chiropractor does not have a current and comprehensive procedural coding text they may not be able to accurately decipher the patients health care records. This lapse may subject them to additional malpractice risk.

Statute excerpts

Ins 3.65 Standardized claim format.

(1) PURPOSE; APPLICABILITY. This section implements s. 632.725 (2) (a) and (b), Stats., by designating and establishing requirements for use of the forms that health care providers in this state shall use on and after July i, 1893, for providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient.

(2) DEFINITIONS. In this section and in s. Ins 3,651:

(a) “ADA dental claim form” means the uniform dental claim form approved by the American dental association for use by dentists.

(b) “CDT-1 codes” means the current dental terminology published by the American dental association.

(c) “CPT-4 codes” means the current procedural terminology published by the American medical association.

(d) “‘DSM-III-R codes” means the American psychiatric association’s codes for mental disorders.

(e) “CMS” means the federal health care financing administration of the U.S. department of health and human services.

(f) “CMS-1450 form” means the health insurance claim form published by CMS for use by institutional providers.

(g) “CMS-15OO form” means the health insurance claim form published by CMS for use by health care professionals.

(h) “HCPCS codes” means CMS’s common procedure coding system which includes all of the following:
1. Level 1 codes which are the CPT-4 codes,
2. Level 2 codes which are codes for procedures for which there are no CPT-4 codes.
3. Levels 1 and 2 modifiers.

(i) “Health care provider” has the meaning given in s. 632.725 (1), Stats.

(j) “ICD-9-CM codes” means the disease codes in the international classification of diseases, 9th revision, clinical modification published by the UIS, department of health and human services,

(k) “Medicare” means Title: XVIII of the federal social security act.

(L) “Medical assistance” means Title XIX of the federal social security act.

(m) “Revenue codes” means the codes which are included in the Wisconsin uniform billing manual and which are established for use by institutional health care providers by the national uniform billing committee.

(3) USE OF CMS-1500 FORM.

(a) Required users; instructions. For providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient, all of the following health care providers shall use the format of the CMS-1500 form, following CMS’s instructions for use:

1. A nurse licensed under ch. 441, Stats.
2. A chiropractor licensed under ch. 446, Stats.
3. A physician, podiatrist or physical therapist licensed under ch. 448, Stats.
4. An occupational therapist, occupational therapy assistant or respiratory care practitioner certified under ch. 448, Stats.
5. An optometrist licensed under ch. 449, Stats.
6. An acupuncturist licensed under ch. 451, Stats.
7. A psychologist license8 under ch. 455, Stats.
8. A speech-language pathologist or audiologist licensed under subch. III of ch. 459, Stats., or a speech and language pathologist licensed by the department of public instruction.
9. A social worker, marriage and family therapist or professional counselor certified under ch. 457, Stats.
10. A partnership of any providers specified under subds. 1. to 9.
11. A corporation of any providers specified under subds. 1. to 9. that provides health care services.
12. An operational cooperative sickness care plan organized under ss. 185.981 to 185.985, Stats., that directly provides services through salaried employees in its own facility.

(b) Coding requirements. In addition to HCF;A’s coding instructions, the following restrictions and conditions apply to the use of the CMS-1500 form:
1. The only coding systems an insurer may require a health care provider to use are the following:
a. HCPCS codes.
b. ICD-9-CM codes.
c. DSM-III-R codes, if no ICD-9-CM code is available.
2. For anesthesia services for which there is no applicable HCPCS level 1 anesthesia code, a health care provider shall use the applicable HCPCS level 1 surgery code.
3. An insurer may not require a health care provider to use any other verbal descriptor with a code or to furnish additional information with the initial submission of a CMS-1500 form except under the following circumstances:
a. When the procedure code used describes a treatment or service whish is not otherwise classified.
b. When the procedure code is followed by the CPT-4 modifier 22, 52 or 99. A health care provider casing the modifier 99 may use item 19 of the CMS-1500 form to explain the multiple modifiers.
c. When required by a contract between the insurer and health care provider.
4. A health care provider may use item 19 of the CMS-1500 form to indicate that the form is an amended version of a form previously submitted to the same insurer by inserting the word “amended” in the space provided.

(c) Use unique identifiers. In completing the CMS-1500 form, the individual or entity filing the claim shall do all of the following:
1. In item 17a, use the unique physician identifier number assigned by CMS or, if the physician does not have such a number, the physician’s taxpayer identification number assigned by the U.S. internal revenue service.
2. In item 33, use both of the following:
a. The name and address of the payee.
b. The unique physician identifier number assigned by CMS to the individual health care provider who performed the procedure or ordered the service or, if the individual does not have such a number, the individual’s taxpayer identification number assigned by the U.S. internal revenue service.