There usually comes a time in every massage therapist's career where she wonders if billing insurance companies for clients’ care is the right move to make. It is a big decision, and requires a comprehensive understanding of the complex arrangement between the client, the referring physician (if required), and you.
Insurance companies only pay for services that are considered medically necessary. Therefore, you must first accept that as a practitioner billing insurance for services, you are considered to be a health-care provider. You must be comfortable with the concept of being part of the health-care system. If that doesn’t feel right for you, your answer is clear—you will not bill insurance for your services.
You also need to educate yourself about the different types of coverage, and know the difference between first-, second-, and third-party billing. You must be willing and able to undertake a never-ending process of research: each state and each insurance company has its own policies and procedures, and you will need to stay compliant. You will spend a great deal of time researching laws, trends, and procedures for working with medical professionals, insurance companies, and attorneys—not just once, but continuously, as this information is always changing.
Insurance billing is a huge topic, and we can only scratch the surface here, but this article will give you an overview of things to consider.

7 Questions to Ask Yourself
Before deciding whether this is the right move for your practice, consider these questions:
1. How often do my clients ask if I can bill their insurance?
2. How many of my clients have health insurance that covers massage therapy or other manual therapy?
3. Will my practice grow significantly if I offer insurance billing?
4. What changes would I need to make to my practice? Am I prepared to accommodate the amount of additional documentation, follow-up, and paperwork required?
5. Which types of insurance am I willing to accept? How does this complement or impact my current practice?
6. Should I hire/contract a medical biller to assist in serving this part of my practice?
7. Am I able to handle the lack of cash flow while waiting for payments from the insurance company?
Your ability to wait for payment is one of the most important factors to consider. Legally, insurance companies have up to 60 days to respond to your submission of a claim. When that response comes, it may be a denial of payment, or a payment for a reduced amount. If that happens, you must resubmit the claim, or you will not get paid—and in cases where you are billing workers’ compensation insurance, you are forbidden to attempt to bill the client. You must be able to run your business without that income until (and if) you receive it from the insurance company.

Types of Insurance
There are four major categories of insurance coverage that can be billed by health-care providers. Each category operates differently, and in each case, state law will determine whether a massage therapist is even allowed to bill insurance in that category.

Major Medical
This is what most people think of in the context of billing health insurance: major insurance providers such as Aetna, Blue Cross, or Blue Shield. It is the most difficult and complicated category of billing.
• You must bill using procedural and modality billing codes.
• The client must have a doctor’s prescription for your care.
• Your care must follow the prescription.
• It usually does not pay in full, so your claim amount will be reduced.
• It will be based on whether or not you are an “In Network” or “Out of Network” provider.

Workers’ Compensation
This type of insurance covers care for workers’ injuries on the job. It is the second most difficult billing category to manage: there are different procedures for government jobs, city and state jobs, and workers at private companies.
You must bill using procedural and modality billing codes, which will differ based on the type of case—federal, state, or private.
• The client must have a doctor’s prescription for your care.
• Your care must follow the prescription.
• It usually does not pay in full.
• It requires a tremendous amount of ongoing authorization and follow-up.
Motor Vehicle Accident (MVA)
Billing MVA insurance companies (such as AAA, Allstate, or Geico) is somewhat easier than the other categories described here. If you choose to begin billing, I suggest starting with this type.
• You must bill using procedural and modality billing codes.
• The client may or may not need a doctor’s prescription for your care.
• It usually pays in full.

Medicare/Medicaid
This government-provided insurance covers care for people living in poverty, children in foster care, adults over the age of 65, those on social security disability insurance, or those who have been diagnosed with certain diseases. As a massage therapist, you are not able to bill Medicare or Medicaid; federal payers do not deem massage therapy as medically necessary and will not reimburse for it.  

Eligibility to Bill Insurance

How do you know if you’re able to bill insurance for your services? There are several factors, including state laws, contractual agreements, and the client’s own policy specifications. You’ll need to investigate all of these areas prior to working with the client.
Clients often ask if you accept their insurance. A more appropriate question would be whether the client’s insurance company accepts you. Each insurance company has its own application process for those hoping to be recognized as an approved health-care provider, sometimes including a fee to apply and/or maintain that status.
Visit an insurance company’s website to learn about its billing policies and procedures. Good information to understand includes acceptable procedure codes, billing formats, reimbursement rates, billing address, and phone numbers.
The type of massage you provide is not the deciding factor in whether you can bill insurance. As long as the client’s physician has written a prescription for it and considers it medically necessary, massage therapy may be eligible for reimbursement.
The key is that there is a physical problem, the client is going to receive massage therapy or bodywork for that problem, and the problem will improve or resolve as a result of the session. This leads to the next thing you need to know: how to document your results.

What Insurance Companies Want
Insurance companies are looking for (1) a specific condition or diagnosis to be treated; (2) parameters for treatment; and (3) changes in function as a result of treatment. They want documented evidence of continuous improvement as a result of your work, usually shown by the client’s ability to perform activities of daily living
and/or the client’s ability to do his or her job.
Massage therapists tend to focus on pain relief; however, functional gains are the key to reimbursement. You must clearly document the client's condition and symptoms at the start of your care, as well as your massage treatment and the outcome of each session. Use of the accepted SOAP (Subjective, Objective, Assessment, Plan) documentation process is recommended.
It is essential to identify specifically how your client is limited by his or her condition or symptoms and formulate a therapy plan to address it through massage. Each session must be documented. Some insurance companies require you to submit your notes along with each claim.
Remember, you are treating with the intention of improving function, reducing pain, or achieving a clinical outcome, based on the diagnosis. Typically, insurance companies will not reimburse for palliative or maintenance care that is not working toward improvement or resolution of a specific, diagnosed condition.
Diana Thompson’s book Hands Heal (Lippincott Williams & Wilkins, 2011; www.lww.com) is a tremendous resource for client intake processes and documentation, and includes specific forms and strategies for documenting treatments to be billed to insurance companies. Another solid resource is Vivian Madison-Mahoney's Manipulate Your Future manual available at www.massageinsurancebilling.com.

Verifying Coverage

Confirming, or verifying, insurance coverage is when you contact the insurance company on your client's behalf to confirm they have coverage. If you perform services not covered by the client’s insurance, the client is ultimately responsible for paying the bill (unless it is a workers’ compensation case).
It is not unreasonable to ask clients to confirm their own coverage prior to their first appointment with you, but it is best practice for you to do it; that way, you are sure that the client is covered.
On the back of the client’s insurance card there is usually a phone number for providers to call. Call the insurance company to confirm coverage. During the call, you will:
• Give the client’s identification number; any group, policy, claim, or plan numbers; the client’s date of birth; and the name of the person the plan is under.
• Tell the insurance company which CPT billing codes you will most likely be using (see CPT Codes, page 52) and verify that they will cover those codes.
• Check that the policy covers massage administered by a massage therapist. Many policies only cover massage administered by a physical therapist, physical therapy assistant, or chiropractor.
• Ask if there are any dollar amount or visit limitations for massage. It is common for massage therapy to be lumped in with other rehabilitative therapies including physical and occupational therapy, so be sure to find out how much coverage the client has, how much coverage has been used, and when the amount “rolls” or renews.
• Check on deductibles and copays (the amount the client is responsible for paying out of pocket).
• Find out if the client requires a referral from his or her primary care provider. Many insurance plans identify a primary care provider (PCP) who is responsible for managing referrals to specialists such as a massage therapist. You may not be paid if a different provider referred the client to you.

Getting Authorization
Getting authorization to treat is when you contact the insurance company and ask them to give you authorization to treat their insured (your client). This authorization does not guarantee you will be paid.



Prescriptions/Referrals for Care

After you have confirmed that you are an authorized provider, that the client has coverage for the services
you provide, and that the client is
being treated for a specific diagnosis, you should ask for the client’s referral. A referral is a prescription for
massage (sample available under “Client Forms” in the Members section of www.abmp.com). This document will guide your treatment plan: it describes why you are seeing the client, the type of treatment you are expected to perform, in what region you should focus your efforts, how often you will see the client, and for how long.
The referral must include the client’s name, ICD-9 or 10 code (see sidebar page 52), date of referral, treatment requested, and duration and frequency of treatment. Be sure it is signed by the referring physician and contains the contact information for that provider. If any information is missing, you will need to contact the referring physician and obtain a completed referral form prior to seeing the client.
Most insurance companies will request a copy of this document when you send in your claim, so be sure it is complete, accurate, and current.
You will not be reimbursed if the referral has expired or has missing information.

Sending the Bill

Specific procedures for billing should be outlined in your provider contract with the insurance company, or you can call the company directly and ask what they need from you. You will most often use a standard form for billing. The current form is the HCFA/CMS 1500, last revised in February 2012. Basic information you will provide on the form includes:
• Your name, address, contact information, and NPI
• Your client’s personal and contact information
• Date of injury/onset of illness
• Name and NPI of referring physician
• ICD-9 or 10 code(s)
• CPT codes
• Dates of service
• Complete prescription from referring physician
This link has a tremendous amount of information to help you understand the intricacies of the form:
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/form_cms-1500_fact_sheet.pdf.
Many insurance companies now require electronic billing rather than mail-in. You may need to purchase software that contains the proper CMS 1500 format and capacity to submit bills electronically. If you want or need to use electronic billing, there are many companies offering medical billing software to assist you. Many have free plans, as well as paid plans. Four examples are Free Medical Claims (www.freemedicalclaims.com), Office Ally (www.officeally.com), Practice Fusion (www.practicefusion.com/medical-billing), and Practice Suite (www.practicesuite.com).
Some insurance companies require that you submit your documentation (chart notes or progress reports) in addition to the form. Be sure to check where to send the documentation and billing, as addresses are not always the same for each piece.
If you will be submitting claims via fax or mail, it is strongly recommended you use a Tax ID number rather than your social security number, and include your NPI.

Working with Legal Cases
If you have a client whose injury or condition means attorneys are involved in the case (for example, a motor vehicle accident), prepare to receive requests for documentation from both sides of the case on multiple occasions.
Even if your client has not told you they will be working with an attorney, you may receive a notice from an attorney to submit your records and billing information—sometimes long after the client has finished treatment with you.
Don’t be alarmed if you receive a visit from a person with a subpoena for records. Providing these materials, usually by a specified date, is not optional.
The attorney should provide a current written permission release from the client along with the request for records. Absolutely do not release chart notes or billing records to an attorney without a signed release from the client. You are allowed to bill a fee to the attorneys for administrative costs and per-page copying in order to provide the information to them.

HIPAA Compliance
The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress in 1996. In general, it serves three purposes: (1) make health insurance more portable for individuals who change jobs, (2) simplify health-care record keeping by requiring some standardization, and (3) enhance patient privacy.
The first two aspects affect you only if you submit insurance information and/or billing information electronically (or if you hire a third party to handle those tasks on your behalf).
The privacy requirements, however, apply to all health-care providers—and, as mentioned, if you bill insurance you are a health-care provider. You must familiarize yourself with privacy rights according to HIPAA and implement them in your practice. All clients should review your privacy policies and indicate in writing that they understand their rights and responsibilities under HIPAA.
Conscientious massage therapists record an initial health history for each new client (a form is available under “Client Forms” in the Members section of www.abmp.com) and also ask clients on each subsequent visit whether anything is new on the health front, making note of any significant changes. You have a responsibility under law (both HIPAA and other laws in many states) to maintain these client files in a secure place, and not to wrongly disclose to third parties information linking an identifiable client to a particular medical condition or treatment. If you practice with other individuals, or work with employees, you are also responsible for training those individuals about confidentiality requirements.
HIPAA compliance is far too complex to cover here, but it is important that you are aware this compliance is required of you as a health-care provider billing insurance. (See “Your Practice & HIPAA,” Massage & Bodywork, March/April 2014, page 82, for more information.) For additional information, visit www.hhs.gov/ocr/hipaa.

Summary
As you can see, there is much more to billing insurance than one might think at first glance. If you choose to undertake this new adventure, you will be rewarded with the opportunity to treat more clients who might not otherwise have the ability to see you. However, there will be a steep learning curve and possibly a loss of income compared to your current practice.
Many massage therapists think billing insurance is the next step up in growing their practice—and it may be, for the right business model and the right type of practitioner. Be aware, though: many well-established health-care providers, including chiropractors, physical therapists, and even physicians, are trying to move in the opposite direction, integrating a cash-only practice to simplify their overhead and time commitment.
Once you’ve looked at all the variables, you will be able to make an educated decision.

A Critical Relationship

CPT Codes
CPT codes are used as a standardized way to accurately describe medical, surgical, treatment, and diagnostic services. There are approximately 7,800 five-digit CPT codes, ranging from 00100 through 99499. An additional two digits are sometimes added to clarify or modify the description of the procedure. CPT codes are updated continuously by the American Medical Association, and are used by most insurance companies.
Which codes you may bill are dictated by the state in which you practice, your scope of practice, license, and provider agreements. Most insurance companies will reimburse 97124, the CPT code for massage therapy. Some may also recognize other codes, such as 97140 (manual therapy) and 97122 (neuromuscular reeducation). It is important that you clarify with the insurance company which CPT codes you are eligible to bill.
It is also imperative that you know what each code stands for. If it is a modality code, you must know how many modalities you are allowed to bill for in a single session.
If it is a procedure code, you need to know if it is time-based, and if so, how much time it allows. Standard appointment times are 60 minutes; if you need more time, you usually need to get prior authorization. (As a side note, it is legal to bill for 60 minutes and only provide 50 minutes of therapy, allowing you to take 10 minutes to complete your documentation.)

ICD Codes

ICD codes are diagnostic and can only be assigned by a doctor. They identify specific signs, symptoms, injuries, diseases, and conditions, and indicate exactly what you are going to address. Doctors can assign as many codes as are needed to describe the patient’s condition.
Because insurance only pays for medically necessary treatments, you always need an ICD code from the client’s physician, even if the client self-refers.
The current ICD code system is in its ninth edition, so codes are designated ICD-9. The next edition, ICD-10, should be in use by October 1, 2015.

Need More Information?
• Active myofascial therapist and business-success coach Irene Diamond works with therapists who want to grow their practices, make more money, and have more happiness. Massage & Bodywork readers can request a free audio CD in which Diamond interviews three other experts in the massage profession about their secrets to success. For a free seven-day course, “Get One New Client A Day Marketing Blitz,” visit www.massagesuccess.org. For more information, visit www.irenediamond.com.
• Body Well Therapy is an LMT-owned and managed massage-services company, specializing in massage for injury victims through insurance (primarily auto and workers’ comp claims). Body Well offers therapists who don’t want to handle their own insurance billing the opportunity to work with these clients as a Body Well independent contractor. Body Well directly coordinates and bills therapy services. Clients may request any specific qualified massage therapist they wish to provide their therapy. Requested therapists not already under contract can be easily contracted by Body Well to provide the prescribed services at a specified frequency, and at a guaranteed rate of pay per session. Services can occur at a client’s home or in a massage establishment. Services are available in all states that license massage therapists.
Therapists can learn more at www.bodywelltherapy.com/accept-insurance-massage, or call 888-929-9355, ext. 3.
 • Vivian Madison-Mahoney, LMT, has been educating
massage therapists about massage insurance billing and marketing for 25 years. For more information, visit
www.massageinsurancebilling.com or call 865-436-3573.

Your NPI Number
Since 1996, health-care providers have been required by the federal government to have a National Provider Identifier (NPI) number. Getting your own NPI number is a free, simple process that includes providing your state license number. If you are in a state that is unlicensed, you may want to call the toll-free number below to ask if you may use a national certification or another method to verify your qualifications.
Contact the NPI Enumerator program via any of the following methods:
• Phone: 800-465-3203
• TTY: 800-692-2326
• Email: customerservice@npienumerator.com
• Mail: NPI Enumerator, PO Box 6059, Fargo, ND 58108-6059
• Online: Go to https://nppes.cms.hhs.gov/NPPES/Welcome.do,
click on “Apply Online,” and follow the steps. Most of the registration process is straightforward. When you get to “Taxonomy,” select “22: Respiratory, Rehabilitative & Restorative Service Provider,” then scroll down to “Massage Therapist.”

Irene Diamond, RT, consults with many of the most successful wellness providers, helping them double their client base and generate more repeat and referral business. Creator of the rehabilitation technique Active Myofascial Therapy—The Diamond Method, and founder of Dream Practice Mastery Academy, Diamond is a 2013 Massage Hall of Fame inductee. For more information, visit www.irenediamond.com.