Neuromuscular Re-education (NMR) Code 97112: Friend or Foe?

Understanding the proper use of code 97112 will benefit not only insurance carriers, but you and your practice as well.

The proper reporting of neuromuscular re-education (NMR) is one of the more significant coding dilemmas faced by chiropractors. This is partly because many definitions of NMR exist, and there are many different interpretations of these definitions.

While there isn’t one universally accepted definition, it generally refers to a treatment technique or exercise performed by an individual with the purpose of improving — via the nervous system — the level of communication between the body and the brain.

The NMR process also encompasses proprioceptive training. Proprioception is defined as the sense of the relative position of neighboring parts of the body.

The proprioceptive system provides feedback solely on the status of the body internally. It is the sense that indicates whether the body is moving with required effort, as well as where the various parts of the body are located in relation to each other.

There are clinical indications for providing proprioceptive training by a chiropractor. The more significant quandary to solve, however, is how to report the work you’re doing, and whether that is by the code 97112.

CPT defines NMR as follows: 97112 therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.

In describing what services can be included under this code, the American Medical Association (AMA) has clarified that “some common examples of this service include proprioceptive neuromuscular facilitation (PNF), Feldenkrais, Bobath, BAPS’ Boards, and desensitization techniques.”

Given this code is a therapeutic procedure, it requires complete one-on-one attendance during the therapy. Depending on your state rule, that could mean with the doctor or a qualified and properly trained team member.

Because the description of this code includes PNF stretching, it’s often billed in chiropractic offices for muscle work performed by a doctor or massage therapist.

The AMA has clarified, saying, the description of the service is more specific.

From a CPT coding perspective, code 97112 is intended to identify therapeutic exercise designed to retrain a body part to perform some task the body part was previously able to do. It is not intended to identify massage to increase circulation, etc.

For this reason, it’s strongly recommended you don’t use 97112 for muscle-related work within the confines of a chiropractic treatment plan. There are other codes better suited for describing this type of work.

Additionally, doctors who practice certain techniques may use a wobble chair or vibration plate and describe it as NMR and code it 97112.

Patients using the wobble chair or vibration plate are often doing so without direct one-on-one attendance and without proper documentation of why these services are being provided. For that reason, using code 97112 is problematic.

From an insurance billing perspective, utilizing code 97112 requires a significant amount of medical necessity and the ability to meet the medical review policy of the carrier.

For example: Aetna has a very specific medical review policy concerning the use of 97112.

John Davila, DC, a recognized expert in compliance for the profession, says:

“In the defense of chiropractors from insurance company audits, we have seen carriers use little known policies to restrict the use of 97112. Here is an example of how Aetna places a restriction on 97112/NMR as seen in Aetna’s Clinical Policy Bulletin:

Physical Therapy Services – Number: 0325

Neuromuscular Re-education – This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception to a person who has had muscle paralysis and is undergoing recovery or regeneration. Goal is to develop conscious control of individual muscles and awareness of position of extremities. The procedure may be considered medically necessary for impairments which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity) that may result from disease or injury such as severe trauma to nervous system, cerebral vascular accident and systemic neurological disease. Standard treatment is 12 to 18 visits within a 4-6 week period.

In these types of scenarios where the doctor incorrectly reported the service to the carrier, there is little chance of the doctor’s victory because now the issue is not as nebulous as medical necessity. Now the issue at hand becomes, was the doctor’s billing compliant with the insurance carrier’s policies.”

Aetna is not the only entity to imply that 97112 is best used for treatment of an upper motor neuron lesion. Certain Blue Cross Blue Shield carriers consider 97112 to be experimental. In the vignette of the service that would describe the use of 97112 from the AMA, they clearly indicate a scenario in which the treatment is for a cerebrovascular accident (CVA).

A woman has a right CVA resulting in a left spastic hemiplegia. Although she can move her arm, she has no functional use of it, as her increased muscle tone results in a flexion synergy in which she adducts her shoulder, flexes her elbow, and pulls her hand into a tight fist. In order to diminish the spasticity during her daily activities, the provider applies deep pressure, then internally rotates the patient’s upper arm, extends the elbows, pronates the forearm, and extends the patient’s fingers and thumb. This combination of movements releases the spasm, and with manual guiding from the provider, the patient is able to practice grasping, holding, and releasing large objects.

Because neuromuscular re-education is such a confusing service to fit into a standard chiropractic treatment plan, it’s recommended doctors educate themselves completely about the proper use of the code.

Typically, active rehab programs include the functional goal to improve a patient’s ability to do something they now lack the ability to do.

Many of these services commonly performed in chiropractic offices would be accurately described using code 97110, therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

It relies greatly on the functional goals stated by the doctor and the components of the treatment plan to get the patient to maximum improvement.

If you’re going to use muscular re-education in your practice, be sure to clearly understand the medical necessity guidelines, a carrier’s medical review policy regarding the code, and your desired outcomes.

Original article can be found here