ICD -10 codes for Massage Therapists

ICD10 for massage therapists

Yes ICD -10 codes are here and there is a lot of information that you will need to know.  International Statistical Classification of Diseases and Related Health Problems codes are created by the World Health Organization and are used around the world.  They are diagnosis codes that are used when doctors prescribe massage so you will need to be up on what is going on.

We are currently using ICD-9 codes which were created 35 years ago and are really out of date.   The ICD 10 codes were created in 1990 and all of the other countries who use the ICD coding system are already using them.  The US is way behind on this one.

The next version – ICD-11 are already on the way expected in 2017 or 2018.   There was of course many controversies over this because changing the codes means that all the doctors and all of the computers need to be updated every time which is of course a major project.  There was a lot of discussion saying that we should go right to ICD-11 but the rationale is that the ICD-10 is such a big change and is a foundation for the ICD-11’s.

ICD-9-CM codes 5 digits

  •  First digit is alpha (E or V) or numeric
  • Digits 2-5 are numeric
  • Decimal is placed after the third character
  • 14,000 codes

ICD-10-CM codes are 7 digits

  • Digit 1 is alpha.The two main category of codes massage therapists will see most of are the M and S codes:
    • M = musculoskeletal or connective tissue condition
    • S = injury or consequences of external causes
  • Digit 2 is numeric
    M00-M25 Arthropathies

    • (M00-M03) Infectious arthropathies
    • (M05-M14) Inflammatory polyarthropathies
    • (M15-M19) Arthrosis
    • (M20-M25) Other joint disorders
    • M40-M54 Dorsopathies
    •  (M50-M54) Other dorsopathies(M45-M49) Spondylopathies(M40-M43) Deforming dorsopathies
    • M60-M79 Soft tissue disorders
    • (M60-M63) Disorders of muscles
    • (M65-M68) Disorders of synovium and tendon
    • (M70-M79) Other soft tissue disorders
    • M80-M90 Osteopathies
    • M91-M94 Chondropathies
    • M95-M99 Other disorders of the musculoskeletal system and connective tissue
    • S00-T14 – Injury
      • (S00-S09) head
      • (S10-S19) neck
      • (S20-S29) thorax
      • (S30-S39) abdomen, lower back, lumbar spine and pelvis
      • (S40-S49) shoulder and upper arm
      • (S50-S59) elbow and forearm
      • (S60-S69) wrist and hand
      • (S70-S79) hip and thigh
      • (S80-S89) knee and lower leg
      • (S90-S99) ankle and foot
      • (T00-T07) involving multiple body regions
      • (T08-T14) unspecified parts of trunk, limb or body region
  • Digits 3–6 are alpha or numeric
    For “M” and “S” category codes, the side of the body is indicated.   Generally:

    • 1 = right
    • 2 = left
    • Note: There are a variety of different methods for denoting bilateral locations
  • Decimal is placed after the third character
  • 7th digit is a special extension code that will be alphabetical and is required for injury codes that start with S.
    The “A” code for initial encounter is used for all sessions related to the “active” treatment for the symptoms called out in the ICD10 code. The “D” code is used for subsequent treatments to check on the patient/client after active treatment is completed

    • A: Initial Encounter – Patient is receiving active care
    • D: Subsequent Encounter  -After patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.
    • S: Sequelae — Complications or conditions that arise as a direct result of the condition
    • Fractures have a different extension code than other conditions based on open vs. closed, routine vs delayed healing, non-union or malunion.
    • For codes that are 3 to 5 characters, the place holder “x” is used to fill in the empty character fields with the extension code at the end. An example is:
    S80 Superficial injury of knee and lower leg
    S80.0 Contusion of knee
    S80.00 Contusion of unspecified knee
    S80.00XA …… initial encounter
    S80.00XD …… subsequent encounter
    S80.00XS …… sequela
  • 69,000 codes to better capture specificity

Read more on the code structure at ICD-10 basics from www.roadto10.org

ICD-10 codes will provide specific locations for injuries. They will also document chronic or acute pain issues.  The new codes are much more specific and will provide us with much more information about diseases and their treatments which will help with health management and research.

Since these are diagnosis codes and massage therapists can not diagnose clients, the codes will come from the doctor.  The doctor may or may not write the actual description of what the code means so you may have to look the code up to know what it means.   There are many free code look up databases online.  See ICD 10 Look up from CMS.

Here also are some common orthopedic codes that are used for rehabilitation from  Road to 10.

  • M54.2  Cervicalgia
  • M50.01 Cervical disc disorder with myelopathy, occipito-atlanto-axial region
  • M50.02  Cervical disc disorder with myelopathy, mid-cervical region
  • M50.03 Cervical disc disorder with myelopathy, cervicothoracic region
  • M54.30*  Sciatica, unspecified side
  • M54.31  Sciatica, right side
  • M54.32  Sciatica, left side
  • M54.40*  Lumbago with sciatica, unspecified side
  • M54.41 Lumbago with sciatica, right side
  • M54.42  Lumbago with sciatica, left side

Here are common pain codes:

  • Shoulder — M25.511 (R), M25.512 (L)
  • Upper Arm — M79.621 (R), M79.622 (L)
  • Elbow — M25.521 (R), M25.522 (L)
  • Forearm — M79.631 (R), M79.632 (L)
  • Wrist — M25.531 (R), M25.532 (L)
  • Hand — M79.641 (R), M79.642 (L) (excludes fingers)
  • Hip — M25.551 (R), M25.552 (L)
  • Thigh — M79.651 (R), M79.652 (L)
  • Knee — M25.561 (R), M25.562 (L)
  • Lower Leg — M79.661 (R), M79.662 (L)
  • Ankle — M25.571 (R), M25.572 (L) (excludes foot/toes)
  • Foot — M79.671 (R), M79.672 (L) (excludes toes)
  • Thoracic Spine — M54.6
  • Low Back Pain — M54.5

As you can see, these codes are much more specific so that will give you so much more information.

You can actually start using these now and you should actually start using them now.  You can start by just using it on like 10% of your clients to test the systems.  You will have to ask the doctors to start supplying the codes.  The reason for starting with them now is because we don’t know how all of the billing and insurance systems will work with handling the new codes although there has been extensive testing.  There could be delays in processing as everyone starts using the new codes.

Other resources:

CMS Provider resources

Road to 10

World Health Organization

Originally written Aug 6th 2015.  Updated Jan 30 2016

ICD 10 codes for massage therapists


Why is the massage profession so far behind in getting massage recognized as health care?

Massage therapists in WA State have been able to bill health insurance since around 1999. How is it that all of the other states lag behind in being integrated into healthcare?

How is it that WA State massage therapists are so far ahead of all of the other states as far as being involved in Health Care?

Is it more education?  No.  We have had 500 hours of required training since about 1989.

The one thing that has made the difference in WA State, is that there are people who are willing to stand up for the massage profession and help make changes.

How is it that we are even Health Care providers in WA?  It was actually by accident almost.   In around 1985 ish, some legislator inadvertently added massage therapy to the list of Health care providers.  Two massage therapists, Taya Countryman and Susan Rosen contacted the legislature and asked about it.  The legislator was going to take it off, but the two massage therapists took a chance and talked to them and showed them just how massage belonged under health care.   (This was told to me by Taya just recently – I didn’t know all that!) There it is: People standing up for the massage profession.

In WA State, Massage Therapists are able to contracted providers with health insurance companies under the Every Category Law (WAC 284-43-205)  created by Deborah Senn the insurance commissioner of WA state at the time (1993.) This was part of the Health Care Reform Act in WA.  (Yes we had a health care reform act way before the ACA of 2010)

The law reads:

Every category of health care providers.

(1) To effectuate the requirement of RCW 48.43.045 that health plans provide coverage for treatments and services by every category of provider, health carriers shall not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for conditions covered by basic health plan (BHP) services as defined by RCW 48.43.005(4). If the BHP covers the condition, the carrier may not exclude a category of provider who is licensed to provide services for that condition, and is acting within the scope of practice, unless such services would not meet the carrier’s standards pursuant to RCW 48.43.045 (1)(b). For example, if the BHP provides coverage for outpatient treatment of lower back pain, any category of provider that provides cost-effective and clinically efficacious outpatient treatment for lower back pain within its scope practice and otherwise abides by standards pursuant to RCW 48.43.045 (1)(b) may not be excluded from the network.
(2) RCW 48.43.045 (1)(b) permits health carriers to require providers to abide by certain standards. These standards may not be used in a manner designed to exclude categories of providers unreasonably. For example, health carriers may not decide that a particular category of provider can never render any cost-effective or clinically efficacious services and thereby exclude that category of provider completely from health plans on that basis. However, health carriers may determine that particular services for particular conditions by particular categories of providers are not cost-effective or clinically efficacious, and may exclude such services from coverage or reimbursement under a health plan. Any such determinations must be supported by relevant information or evidence of the type usually considered and relied upon in making determinations of cost-effectiveness or clinical efficacy.
(3) Health plans are not prohibited by this section from placing reasonable limits on individual services rendered by specific categories of providers. However, health plans may not contain unreasonable limits, and may not include limits on the type of provider permitted to render the covered service unless such limits comply with RCW 48.43.045 (1)(b).
(4) This section does not prohibit health plans from using restricted networks. Health carriers offering plans with restricted networks may select the individual providers in any category of provider with whom they will contract or whom they will reimburse. A health carrier is not required by RCW 48.43.045 or this section to accede to a request by any individual provider for inclusion in any network for any health plan. Health plans that use “gatekeepers” for access to specialist providers may use them for access to specified categories of providers.
(5) Health carriers may not offer coverage for health services for certain categories of providers solely as a separately priced optional benefit.
(6) The insurance commissioner may grant reasonable temporary extensions of time for implementation of RCW 48.43.045 or this section, or any part thereof, for good cause shown.
(7) All health carriers and their plans, provider contracts, networks and operations shall conform to the provisions of this section WAC 284-43-205, by January 1, 2000.

[Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050 and 48.46.200. WSR 99-16-036 (Matter No. R 98-20), § 284-43-205, filed 7/28/99, effective 8/28/99)

I have seen Deborah Senn speak at a few conventions and have heard her explain how it all came to be.  Basically, she had a massage therapist who helped her get better and this massage therapist – Lori Grassi (formerly Belinski) was very politically active and a member of AMTA-WA. (I also heard that Lori  might have worked with Deborah Senn in her law office.)  Together they created the law. The statute was supposed to go into effect on Jan 1, 1996. The insurance companies fought the law for many years until finally in about 2000, there was a US Supreme Court decision that upheld the law in 1999 and made it so.  It took another few years to implement and get the insurance companies organized.  Senn was taking a stand and making a difference for the massage profession in WA State.

There was a Clinician Workgroup that was created and who wrote this report that includes the timeline of events which ends with a Supreme Court Ruling – Issues in Complementary and Alternative Medicine Services.   The workgroup was also instrumental in pulling information together for the insurance companies to help them figure out how to integrate us into their system.

Massage Therapists must first apply to be contracted providers.  The process involves filling out the credentialing application and being approved by each insurance company or their representative organizations.  That process is all done online through www.providersource.com.   You can bill electronically though www.officeally.com and also be paid by direct deposit by many of the companies.  It is getting easier and easier to bill and get paid with the help of technology.

It is also required that you have an NPI number and be HIPAA compliant.  Billing is done electronically along with payments from the insurance company.

Here is a list of the some of the major providers in WA State:

  • Aetna, Cigna, Group Health and Corvel are managed by Whole Health Networks.
  • Premera Blue Cross
  • Regence Blue Shield
  • First Choice Health

On the other hand, most of the provider lists are now closed to new applicants so you may have to get on a waiting list.   The  allowable fees that the insurance companies pay have been reduced in the past 3-5 years.  They used to pay somewhere in the range of $70-$130 for an hour massage and I would say the going rate is more like $60-$70 an hour (including co-pays/co-insurance payments).  The number of sessions allowed keeps getting reduced and one company is requiring pre-authorization and limiting sessions based on their own determining factors which are unknown (to me anyways!)  So overall the process is getting easier to bill and get paid, but the insurance companies are still mainly concerned about their profits.   Self insured companies don’t have to abide by the rules of regular insurance companies so big companies that can afford to create their own health care plans are exempt from having to allow massage therapists to be on their provider lists.  (Although this should have changed under 2706 of the ACA but no one is challenging it – yet.)

The one other good thing is that there are plenty of massage therapists doing just that and there is power in numbers.  You can learn and get support for the extra challenges and issues.  It can help keep your massage business stable in any economy as people will always come in under their insurance when they need it.   Hospitals are looking to massage to help them have better outcomes using massage in headache and pain clinics as well as birthing centers, cancer wards and hospice care.   Wouldn’t it be amazing if massage could be covered on insurance in those cases?

So what is a Massage Therapist and the massage profession to do?  Do you want more regular weekly clients for a short time, that have injuries and health conditions that you have to deal with?  Do you want to keep up to date with all the laws, regulations and procedures?  Do you want to fight the battle for better allowable fees (what you are paid) and for better benefits?  What if massage could be the first line of treatment for the many pain conditions that are often treated with addicting drugs?  What if you could get regular weekly massage to help during stressful times?

If you are wanting to get the health insurance companies in your state to include you in their system here are some things that you can do:

  • Learn to bill insurance so you know what is going on and can see first hand what needs to be done.  Just commit to taking on one or two cases to learn the ropes.  I am not talking about having a full practice of all insurance billing.  I have an easy to read book on the procedures for billing and offer support in a closed Facebook group for any questions you may have on billing insurance.
  • Contact Your Local AMTA Chapter.  They are more politically active.  If your chapter is clueless, then consider starting something and working with the Government relations person to get something going.
  • Gather some friends together to help you.
  • Find out if you are considered to be a healthcare provider in your state.  WA, FL, NY, NC, GA, MI, OH, VA, MD (LMT’s only), WA DC, TN seem to be under this classification.  You have to check in your state health care laws which is a different section usually than just your massage licensing laws.  To get your state to consider you to be a HCP, you will need to do some legislative work.  I know in WA, it was actually almost a fluke that we got that status.  About 20 years ago, one of the law makers mistakenly put massage in the HCP category and when 2 of WA states MT’s saw it they confirmed it and also stood up and proved that we should stay in that category.
  • Contact the office of the insurance commissioner and start asking what will need to be done to implement 2706 of the Affordable care act.  You will most likely need this document (PDF) that was created by AMTA-WA for the WA State Office of the Insurance Commissioner to show that massage is part of the Essential Health Benefits.
  • Contact Integrative Healthcare Policy Consortium ( IHPC ).  They are the only organization I could find that was doing anything actively to get 2706 implemented.  Last year they hired Deborah Senn (WA States past insurance commissioner who created the every category law in WA.) to go to some of the states to see what needed to be done to get the law implemented.  The chiropractors actually were part of hiring her.  She is a great resource.  IHPC could also use money so that they can hire more people to start standing up for us.

AMTA National and other massage associations have let us down.  They should have been working on this across the nation starting in 1996 when Debra Senn created the law here in WA.

We need more massage therapists to start billing so you can see how things works and see what needs to be done.  We need more legislation, more education, more research and more massage therapists getting involved politically to make this all happen.  We need the to get more politicians on our side.   We need YOU to help us change things.

There is POWER in Numbers.

If we are not at the table, you are on the menu ~ John Weeks

If you are not at the table, you're what is for dinner ~ John Weeks-1

Why Massage Insurance Billing?

Can you bill one insurance case in the next 6 months?Massageinsurancebillingchallenge

I suggest you start with a car accident case or a work related injury case.  Right now in most states, you can bill easily for a car accident or worker comp case.

Why am I asking you to do this?

We need you!  The massage profession needs you!

Yes massage insurance billing may seem like a nightmare to you…but it doesn’t have to.  It is just a process of learning what you can and can’t do in order to bill AND get paid.  Don’t let that scare you!

We need more people learning to bill insurance so we can have more people who are aware of how it all works so we can have more people standing up for us with the insurance companies and medical professionals.  We need more people at the table working for the massage profession to make more changes and to show the insurance companies and medical professionals that massage does work and it could really help reduce costs in the insurance world and patients would be much happier when they can avoid surgeries and pain meds that make them feel awful in other ways.  (Personally, I do not recommend having your whole practice be based on medical billing as thing are changing so rapidly with new CPT codes coming out in 2018 and new ICD-10 codes coming in Oct 2015.  Those changes will take time to implement and incorporate into billing services meaning times for payment could be delayed greatly.)

We need more massage therapists learning about documenting their massage sessions through SOAP notes and putting what we do in a massage session into words the medical professionals and insurance companies will respect and understand.  Our chart notes are what will show doctors and insurance companies that massage does work and that massage therapists know what they are doing.   Our chart notes will show progress in clients/patients and help give massage the respect it deserves.  Charting is much more then just saying people have tight muscles and you released them.  The best resource on charting is the book Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists .

With so many challenges around being a Health Care Provider (HCP) , we will need associations hiring lawyers to help us navigate the legalities of being a HCP. We need lawyers and lobbyists in every state. It is different than just being a massage therapist.  There are more responsibilities around privacy and doing business as a HCP.

States will need more help with licensing and legislation issues to help states that are not HCP’s to obtain that status in their state.  Currently, the states that I know of that are licensed as HCP’s are: WA, NY, FL, MI, WI, NC, GA, AL, TN, VI, CT, MD (LMTs only), WV, Wa DC, OR. NM, MO and possibly TX.  We need more information on this to determine each states status and be working to get the other states on this list.  In most states, massage therapists can already bill for car accidents and/or work related injuries even without being in the official HCP category.   I also think that could help the efforts to get recognized by health insurance companies.

We need more research to show how massage works and why it works.  We need more evidence that shows massage can help for the many conditions we constantly work with – headaches, back/neck pain, fibromyalgia, herniated discs, carpal tunnel, thoracic outlet syndrome and more.  Right now we have nothing really that shows without a doubt that massage works.  At best we have research that ‘shows promising’ in the words of Christopher Moyer author of Massage Therapy: Integrating Research and Practice

We need more case studies to base the research on.  The case studies are what come from the people in the massage table trenches doing and seeing the results of the work – that means YOU!  Find out more about writing a case study from www.massagetherapyfoundation.org

What this could mean for you and for the massage profession.

Taking just one insurance case in the next few months or even stepping up to take a few insurance clients a month or even a year, could help make your massage business more profitable.  It is also a great learning experience to work with people with such injuries and health conditions and see people get better.  The more people we have billing and getting involved in the process, the more chances there are for insurance companies and medical professions to learn about what massage really does.  Creating relationships with medical professions and insurance companies is really one of the easiest ways to fill your business with clients too.  People who are injured or in pain or under stress come in weekly or even 2-3 times a week depending on the severity of the case.

For the profession, the more exposure we get, the more we can get our selves out of the idea that massage is Pampering and is somehow just a luxury.  The low cost/low paying, controversial franchise model could get exposed for what it is – mostly mediocre massage.

Billing insurance for massage services is a very complex and always changing process that is usually thought of being more of a pain in the neck than worth the time and energy to do.  While that pain in the neck, can be true with certain cases, the thing is that if you learn how to bill and learn how the insurance companies in you area work, you can easily learn what cases to take and which cases to avoid that will be more time consuming or more difficult to get paid.

2706 of the ACA paves the road for getting paid more by health insurance companies, but no one is working on enforcing it and there are no clauses that site how it will be enforced either.

There is also the Triple Aim framework was developed in 2007 by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance around the world. The Triple Aim is about:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

Massage Therapy would fit nicely into all three categories if only someone or some organizations would start paying attention.  Where are our massage associations?  Still no national lobbyist for massage therapists?  Still no one standing up for the massage profession?

The main thing is that more health insurance companies ARE actually paying for massage services and they are doing so without any input from the profession on the many things that are at stake:  low allowable fees, closed provider lists, dwindling massage benefits.

Don’t be afraid to bill insurance!

Learning to bill insurance may seem like an overwhelming process. It doesn’t have to be when you learn from others and have a forum for asking any and all of your questions.  You can get just that when you purchase my Book in PDF or in paperback – Massage Insurance Billing Manual.

The PDF version which you download immediately and directly to your computer is $32.95 and that includes the billing forms and the entry into the private/closed Facebook group.   Purchase the Massage Insurance Billing Manual PDF Now

The paperback version available through www.amazon.com is $26.95 and DOES NOT include the Facebook forum but you get a special link in the book to take the next step and join the Facebook Group for a small fee. That way I can provide you will all of the updates in the insurance billing world and also help answer your questions.  Buy the Paperback book Now –Massage Insurance Billing 101: Putting the Care Back in Health Care

Bill One Insurance Company for
Massage by Dec 31, 2015! and start making a difference

Putting the Care Back in Health Care!


Issues in Complementary and Alternative Medicine

Issues in Coverage for Complementary and Alternative MedicineFrom the Report of the Clinician Workgroup on the Integration of Complementary and Alternative Medicine January 2000.  Washington State

Report of the Clinician Workgroup on the Inegration of CAM    Page 39
Factual Chronology
Of Legal Events Related to RCW 48.43.045
April 1993    The Washington State legislature adopted the “every
category of provider” mandate as part of the 1993 Health Care Reform Act.

April 1995    The Washington State legislature adopted the every
category of provider mandate in RCW 48.43.045. The statute was to be effective January 1, 1996.

August 1995    The Insurance Commissioner sent a letter dated August
18, 1995 to the CEO’s of all disability insurers, HCSC’s and HMO’s requesting the submission by September 15, 1995, of a time line and work plan for achieving an adequate network of every category of provider.

September 1995    Carriers submitted plans as requested by the Insurance Commissioner.

December 19, 1995    The Insurance Commissioner issued Bulletin 95-9 setting forth the Commissioner’s interpretation of RCW 48.43.045. None of the carriers’ previously submitted plans would satisfy that interpretation.

January 8, 1996    Carriers filed a lawsuit in Thurston County Superior Court, sub nom Blue Cross of Washington and Alaska v. Semi, to have a court decide the correct interpretation of RCW 48.43.045.

April 8, 1996    Superior Court dismissed lawsuit due to carriers lack of exhaustion of their administrative remedies.
May 21, 1996    Carriers filed a Petition for a Declaratory Order to have the Insurance Commissioner decide the correct interpretation of RCW 48.43.045.
August 21, 1996    The Insurance Commissioner issues the Declaratory Order requested by the carriers.

August 1996    Carriers sue the Insurance Commissioner in Thurston County Superior Court, asking the court to reverse the Declaratory Order and stay all enforcement of it.

Page 40    Report of the Clinician Work group on the integration of CAM

September 1996    Carriers sue the Insurance Commissioner in Federal (Employee Retirement Income Security Act) preempts state implementation of RCW 48.43.045 as to employer plans.

September, 1996    Superior Court orders enforcement of Declaratory Order stayed until the court can decide whether the Commissioner interpreted RCW 48.43.045 correctly.

December 11, 1996    Insurance Commissioner convenes carriers and provider groups for discussion regarding RCW 48.43.045.
January 3, 1997    Insurance Commissioner facilitates provider discussions regarding provisions of RCW 48.43.045.
January 6, 1997    Insurance Commissioner facilitates discussions between the carriers and providers regarding RCW 48.43.045. Providers present proposals for implementation.
January 23, 1997    Insurance Commissioner facilitates discussions between carriers and providers regarding RCW 48.43.045. Providers deliver further proposals for implementation.

February 6, 1997    Commissioner reviews measures presented by the carriers for implementation of RCW 48.43.045. Office of the Insurance Commissioner prepares plan matrix of currently covered benefits for alternative providers.

April-May 1997    Commissioner prepares for a facilitated meeting with providers and carriers to discuss clinical aspects of alternative therapies in health plans.

May 2, 1997    Federal District Court rules that ERISA preempts state implementation of RCW 48.43.045.
May 9, 1997    Insurance Commissioner files a motion in Federal District Court to clarify whet.er the court’s May 2nd ruling applies to non-ERISA governed health plans.

May 30, 1997    Insurance Commissioner files an appeal with the 9th Circuit Court of Appeals of the May 2, 1997 ruling that preempts RCW 48.43.045 from ERISA plans.

Report of the Clinician Workgroup on the Integration of CAM    Page 41
May 30, 1997    Insurance Commissioner supports a facilitated meeting of health plan medical director’s and representatives of alternative provider professions discussing clinical aspects of alternative therapies in health plans.
July 23, 1997    Federal district court denies the Commissioner’s motion to clarify the ruling.

July 30, 1997    Insurance Commissioner refiles the appeal to the 9th Circuit Court of Appeals.

September 29, 1997    Washington state brief filed with the Ninth Circuit Court of Appeals. Amicus briefs filed in support of the position of the Office of the Insurance Commissioner by U.S. Department of Labor, National Association of Insurance Commissioners and provider groups.

May 7, 1998    Oral Argument in 9th Circuit Court of Appeals.

June 18, 1998    9th Circuit Court of Appeals reverses the lower court and directs summary judgement be entered in favor of the state.

July 3, 1998    Plaintiffs petition the 9th Circuit for a re-hearing on it’s June 18, decision.

August 24, 1998    Ninth Circuit denies the plaintiffs petition for are-hearing, and rejects the plaintiffs state law arguments under 48.47.005-030, in addition to the ERISA claims rejected in it’s June 18 decision.
September 17, 1998    Plaintiffs notify Thurston County Superior Court they will file a “petition for Writ of Certiorari with the United States Supreme Court” from the decision of the Ninth Circuit.
November, 1998    Plaintiffs filed Writ of Certiorari with the US Supreme Court to review the lower court’s decision.
December 20, 1998    OIC filed a brief in response to the Plaintiffs petition in the US Supreme Court.

January 1999    US Supreme Court denies Plaintiffs petition for Writ of
Certiorari, leaving the decision of the Ninth Circuit Court of Appeals to stand.


See Full PDF of the Report:  ICCAM1ICCAM2,  ICCAM3, ICCAM4, ICCAM5timeline,



WA State Massage Insurance Billing

Massage Therapists are licensed as Health Care Providers. (need citation/resource)WAMassageInsuranceBilling

Every Category Law makes it mandatory that massage therapists be included as providers for health insurance plans.

 Labor and Industries

For Federal Employees – http://owcp.dol.acs-inc.com/portal/main.do

Health Insurance

Apply to become a provider with Health Insurance

Use www.providersource.com

Most of the lists are closed to new providers.  You should still fill out an application and request to be on the waiting list.  You might also want to call them weekly to get on the list.  Another idea is to call the local massage therapists who are in your zip code who are already on the list of providers for that insurance company and ask if they are accepting new clients or find out if they are still in business.  Often times therapists will leave the network but the insurance companies don’t seem to add new therapists.   The insurance companies must provide enough therapists in each geographic area.

Healthways/Whole Health Networks covers Cigna, Aetna, Group Health and Corvel which is a combination of auto insurance companies.

Premera Blue Cross/Lifewise WA

First Choice Health

United Health Care – Use CAQH.org to credential http://www.caqh.org/overview.php

Regence Blue Shield 

Preauthorization for Regence Blue shield required through Carecore.com.

Regence Uniform is exempt from preauthorization as well as some other companies that are self-insured.

Care Core details: 

You can use www.officeally.com for free to bill these companies directly electronically.

Receive EOB’s through officeally.com

In order to receive ERAs (Electronic Remittance Advise) through Office Ally you would want to complete the ERA pre enrollment forms for each payer. To find the ERA enrollment forms you will want to go to Resource Center > Payer Enrollment Forms. On the Payer Enrollment forms you will see the link for Electronic Remittance/ ERA/ 835 Enrollment forms which will take a you to a list of alphabetized payers and their instructions for ERAs.

Receive Payments through direct deposit.  Contact each company to set this up.

 Personal Injury Protection (PIP) Motor Vehicle Collisions

You can also bill massage services for car accidents.  Start with making sure that the client has personal injury protection benefits in their insurance plans.  That will cover the costs up front up to whatever limit they have on their policy making it so that you can get paid right away and not have to wait until the case settles.

Personal Injury Protection is required by law.  The customer can also decline having PIP coverage when they can prove they have health insurance coverage and say they don’t want PIP.   Make sure the customer has this in writing, or PIP must be part of the insurance.

  1. Client will start PIP claim through their insurance.
  2. Prescription required
  3. Confirm benefits and the amount left in the PIP account by calling the claim manager.
  4. Find out where to send the bills and if you will need to send the prescription and chart notes with the bill. (The answer is usually yes.)
  5. Send completed bills.

Third Party Claims

When PIP benefits are used up, the claim moves to a third-party claim.  The insurance of the person at fault will get money at the time of settlement to pay remaining bills.  Be sure to have the client sign an official contract saying that they will pay the bill.



Office of the Insurance Commissioner – http://www.insurance.wa.gov/

Retention of Medical Records – http://www.doh.wa.gov/Portals/1/Documents/3000/MD2013-08RetentionOfMedicalRecords.pdf

CE Requirements – http://app.leg.wa.gov/WAC/default.aspx?cite=246-830-475

Laws and regulations

Massage Businesses must be owned by a Health care provider – Statute Laws (looking for resource on this).  Yes that makes Franchises/spas/Clinics that are not owned by a MT, DC, MD illegal.


WAC 246-08-400 How much can a health care provider charge for searching and duplicating health care records

RCW 25.15.045 Professional limited liability companies.  Massage Therapists must create a PLLC (not a LLC).

RCW 18.100.050 Organization of professional service corporations authorized generally — Architects, engineers, and health care professionals — Nonprofit corporations.

WAC 246-830-040 Equipment and Sanitation -http://app.leg.wa.gov/WAC/default.aspx?cite=246-830-040

Scope of Practice   (6) “Massage” and “massage therapy” mean a health care service involving the external manipulation or pressure of soft tissue for therapeutic purposes. Massage therapy includes techniques such as tapping, compressions, friction, reflexology, Swedish gymnastics or movements, gliding, kneading, shaking, and fascial or connective tissue stretching, with or without the aids of superficial heat, cold, water, lubricants, or salts. Massage therapy does not include diagnosis or attempts to adjust or manipulate any articulations of the body or spine or mobilization of these articulations by the use of a thrusting force, nor does it include genital manipulation. http://app.leg.wa.gov/RCW/default.aspx?cite=18.108.010


L&I – Hiring an Independent Contractor (PDF)

Research Resources

Summary of Evidence (PDF from AMTA-WA website) – How Massage Fits into the Essential Benefits of the ACA.

Heal-wa.org  – Great free resource for licensed massage therapists in WA State. Find research papers, CPT code books and more.

The Future of Massage/Bodywork In Healthcare

I had the pleasure of attending a symposium called The Future of Bodywork: Surviving Corporate Healthcare last night put on by Jack Blackburn and the Trillium Institute in conjunction with Brian Utting and the Pacific Northwest School of Massage and wanted to share my impressions and insights as we move forward in WA State as health care providers.

Deborah Senn, our past insurance commissioner who created the ‘Every Category Law of Providers”  (WAC 284-43-205) was the first to speak.

“Patients want us in the healthcare system!”  According to studies done by David Eisenberg in 1990 and in 2001, 40% of the US wants complementary and alternative medicine (CAM) as a part of their care.  80% don’t tell their doctors that they do!   CAM providers are the future of healthcare.  Massage therapists are CAM providers!  (My Heal-wa.org seems to be down so I can’t find the studies!  www.heal-wa.org is a resource that WA State LMP’s have that allows us access to research papers for free!)

In 1993, Senn created the Every Category Law as a part of the 1993 Health Care Reform Act.   Two years later, that act was repealed but luckily the Every Category Law remained in tact.  Nine insurance companies sued the insurance commissioner and over the course of 3 years, the battle ended in the 9th Court Circuit of Appeals decision to keep the law intact followed by the US Supreme Court decision in Jan 1999 to deny the Writ of Cerioriari leaving the Ninth Circuit Court of Appeals to stand.

(1) Issuers must not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for services covered as essential health benefits, as defined in WAC 284-43-878 and RCW 48.43.715, for individual and small group plans; and as covered by the basic health plan, as defined in RCW 48.43.005(4), for plans other than individual and small groupeverycategoryvs2706

What does this mean?

There is legal precedent to have this happen in every state if someone/some organization/some group would just stand up and help to implement it all.

2010 and the Affordable Care Act comes along with section 2706 which I have previously written about in 2013 Getting Massage Covered by Health Insurance  which states is based on non-discrimination:


(a) Providers- A group health plan and a health insurance issuer offering group or individual health i

nsurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

(b) Individuals- The provisions of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimination) shall apply with respect to a group health plan or health insurance issuer off

ering group or individual health insurance coverage.


2706 applies to all plans and all carriers.  That means that it should apply to ERISA Plans too (See US Dept. of Labor Explanation) – you know those plans like that of Microsoft and other large companies that create their own insurance plans for their employees and hire other companies to mange them.   So why aren’t those plans currently paying?   The question was never proposed or answered.

2706Senn is also a professor at Yale (or was it Harvard…I can’t remember) teaching insurance and she has her students doing the research of finding out which states are implementing 2706 and which are not.  It depends on what states have chosen to implement their own system or to use the Federal Healthcare system.  Her findings so far is that no states are implementing 2706 — so whats a massage therapist/CAM provider to do?

The only group I know of who is working on this is the IHPC (www.ihpc.org).  They hired Senn briefly to start the process but are lacking in funding to go much farther right now.  See Alert: IHPC Launches Campaign with Insurance Commission Deborah Senn to Secure Non-Discrimination
They have just created www.covermycare.org to help get the process rolling.

In my opinion, the massage organizations have fallen behind in this across the US.  Of course the exception is AMTA-WA which has been on this since the ACA and 2706 was made into law.  They hired Diana Thompson and a team of researchers to write a paper to show the WA State Insurance Commissioner that massage was indeed part of the 10 essential benefits. (See Summary of Evidence: (PDF) Massage Therapy is an Integral Component in the Affordable Care Act?s Essential Health Benefits )

 New Massage CPT Codes for all!

Susan Rosen who is a massage therapist in WA State and is an active member of AMTA-WA and AMTA National who was also instrumental in helping to integrate massage into health care under the Every Category Law.  She is currently working on the new CPT codes for Therapeutic Interventions for body Structure and Function through the American Medical Association Current Procedural Terminology (CPT) Health Care Professionals Advisory Committee (HCPAC).

Yes folks 97124, 97140 and 97112 are going far far away….they will be ‘crosswalked out’ (which I don’t know what that means yet!)   The new codes are NOT public knowledge yet and if she told us, she would have to shoot us!  (I was so lucky to be involved in the testing process so I have seen the codes and the same applies!  I feel like I am part of a secret group! Frankly the first thing I said after the study was holy crap – and had many thoughts of moving to a total cash practice but that was just the shock of all the changes….or maybe not!)

The codes are being set by a workgroup of practitioners from PT, OT, and Athletic Trainers.

The codes will be based on the level of complexity of the clients condition and the clinical decision making process, comorbidities and complexity of how you approach a clients care.  Comorbidity is  the presences of other diseases and conditions, like having diabetes and having a hamstring pull.   Physician codes already do that.  The date for the release of the codes is Jan 2016 but Rosen was skeptical that the date could be met.    When the new codes do come out there will be much to do in working with the insurance companies to set the allowable fees.

See more on How a Code is Created from the AMA

Also article on CPT codes in AMTA-WA Journal (PDF)  by Susan Rosen (Page 22).

Rosen recommends we continue to improve our communications and networking with other healthcare professionals to help bring us into this new age of healthcare.

Michael Hamm was the MC and also one of the speakers.  His background in research and teaching made me think more about what we need to do to start communicating better with clients and other healthcare professionals.  It is also about how can we preserve our authenticity in the face of the grueling insurance companies.  We need to start talking about meaningful activities.  When does a client actually know the are ‘better’?

Marissa Brooks who is a past member of the State Board of Massage and currently Director of Health Improvement Programs for the Health Benefits Trust talked more about what she sees happening in healthcare.

Glynn Desmond is one of the AMTA National Member at large and also the owner of the Monroe Therapeutic Massage Clinics around the Seattle area, helped clarify why we don’t have much say in what insurance companies pay us.  Hospitals have much more negotiating power because of the size of the organizations.  If massage therapists try to rebel and fight the system, the main option is to leave the network but the insurance companies don’t really care as they will get more massage therapists to fill their spots.

Questions and Answers

The main questions were around what can we do to get the insurance companies to pay us more and also to get their lists open so that more can become providers.  There is no answer really other than it takes money…we need to hire more attorneys and lobbyists and people to stand up for us.  We do have the AMTA WA who has been doing this consistently through the many years but it just takes more money.

The AMTA WA did get their lawyer to look into the issues with Care Core in limiting the number of treatments they approve through the pre-authorization process which limits sessions to 4- 6 sessions no matter what the condition – if they fell down the slopes skiing or just tweaked their shoulder brushing their teeth- the number of sessions is the same.  Personally, I find the pre-authorization process frustrating but I can also see that it is limiting maintenance massage which is not paid for by health insurance companies.   I do not know how they have come up with the number of sessions that it takes to heal various conditions which is something that needs to be explained.  Senn mentioned that the acupuncturists were also looking into this and I do know that the chiropractors were fighting this without success.  Senn recommended that we contact the Office of the Insurance commissioner with our concerns and most importantly have your clients who are frustrated with the pre-authorization process contact them too.  A fax blitz is recommend if we could ever get our act together! (oh but it looks like they have taken their fax number off of the website – I wonder if it was after someone fax-blitzed Senn!) WA State Insurance Commissioner contact pageFile a complaint page.

As far as getting them to pay us more…well we can’t approach insurance companies through AMTA-WA or any organized group as it will violate anti-trust laws around fee setting.   There is always talk that a Union is needed for that but when most MT are self employed, I am not sure how that would work.

The other thing is to get any further in healthcare we will most likely need more education requirements.  It is “Lucky” really that we are able to do what we are doing with only 500 hours of required education for licensing.  The State Board of Massage has been talking about increasing the hours of eduction so we will have to get involved in that.  You can keep up to date with everything that is going on with the Massage Board by signing up for their listserv and by going to the meetings (but I am sure you all do that now anyways – right?)


What else can you do?

If you are in WA State:

  • Join AMTA-WA or make a donation to AMTA-WA
  • Get involved in the government relations committed of AMTA-WA
  • Get involved with one of the AMTA-WA Units to keep informed of what is going on
  • Write to the Insurance Commissioner and keep them informed of the issues
  • Contact your provider representatives of the insurance companies you are in network with
  • Get your clients involved to contact the insurance companies and the insurance commissioners
  • If you are looking to get on the provider lists, call or contact the companies weekly.
  • If you are looking to get on the provider lists, start with the current provider list of massage therapists and contact each one of them and ask if they are still accepting new clients. Keep track of who is and also keep track if providers have moved or left you area.  Contact the insurance companies with this information.

If you are out of WA State and want to be able to bill health insurance:

  • Contact your local AMTA chapter to see if they are doing anything to implement 2706 in your State.  If they are not doing anything, see if you can start a committee to do so.
  • Contact your States Insurance Commissioners office and ask them what needs to be done to get 2706 implemented and start working with them to implement it.  You will need to hire attorneys and lobbyists to get involved, so it is best to start with AMTA to get organized as they have more influence in this area.
  • Start your own organization like they have in HI to start getting integrated into Healthcare.  See Hawaii Massage Association – Run Away from 2706 (They have other issues with 2706 concerning native healers who would also be included in 2706 and thus would be able to bill for insurance.)
  • Start learning how to bill insurance.  In most states you can bill for car accidents and workers compensation.  You can purchase my ebook on this for starters and join my private Facebook Group to start learning what needs to be done to bill.
  • Start working with Doctors, Physical Therapists, Chiropractors, Naturopaths and join with them in for improving patient care and also for organizing to work with insurance companies.
  • There are already many businesses providing insurance for their employees that DOES cover massage.  BCBS of IL does for starters.  That is without having laws in place.   Start finding out if you can bill certain insurance plans in your state.  Join my group Massage Practice Builder on Facebook to start sharing information.
  • Vote and elect an insurance commissioner that will work with you to implement 2706 or that supports massage therapists.  I asked Deborah Senn about 5 years ago what needs to be done in other states and she just said that they need someone to stand up for them like she did.
  • Get involved with IHPC  and their cover my care program and find out what we can do to support them and move this forward – $$$ /Time
  • Learn the history of  health care integration how it came about in WA State and learn from them/with them through AMTA.
  • Contact AMTA National to see what they are doing as far as hiring a National Lobbyist Team and Attorneys and to get more money and assistance to the State Chapters.
  • If you are an AMTA member, you need to vote to make sure the right people are there to lead us into the future.
  • Get involved someway, somehow, some time.   (A comment was made at the symposium that there were a lot of familiar faces there.  The same people are most ALWAYS involved and (my insight here) the complainers just keep complaining.)


The evening was jam packed with information but I have to say not much was news and there is still much to figure out.  We need to keep the discussions going on this throughout the state.   You can join me at our local NW LMP Support Group at www.meetup.com or continue this at the AMTA-WA Convention in April 2015.

And Join me at the next Symposium on Education.

Why do I keep pursing this with so many challenges?  There is power in numbers…what if massage could be the first response to pain, injuries, diseases and other conditions?

Common ICD-9 codes for Massage Therapists

Common ICD 9 Codes used by doctors when prescribing massage therapy:
Numerical Listing of ICD 9 CM Codes

The referring physician must supply all diagnosis codes. If you determine a code yourself, you are practicing out of your scope of practice and may be found to be practicing illegally in your state. You may lose your license.

There are general pain codes that are supposedly not diagnosis codes that may be used depending on the plan or the rules by the insurance company or in your state.

* Sprain and Stain codes require an extra digit. Use only the indented codes
** Fifth digit instructions will be found at the end of the section.
Sprain – a sprain involves some tearing of ligament tissue
Strain – a strain is the tearing of musculo-tendinous tissue
250 Diabetes
307.81 Tension headache, Tension
311 Depression
337.20 Reflex Sympathetic Dystrophy
– unspecified
337.21 Reflex Sympathetic Dystrophy – upper limbs
337.22 Reflex Sympathetic Dystrophy – lower limbs
337.29 Reflex Sympathetic Dystrophy – Other specified site
340 Multiple sclerosis
344.0 Quadripelgia
344.1 Parapalegia
346.1 Migraine headache – common
345.9 Epilepsy
350.1 Trigeminal Neuralgia
351.0 Bell’s Palsy
351.8 Facial neuralgia
351.0 Facial paralysis
353.0 Thoracic Outlet Syndrome
353.1 Lumbrosacral Plexus Lesion
353.4 Lumbrosacral Root Lesion
353.3 Thoracic Plexus Lesion
354.0 Carpal Tunnel Syndrome
356.9 Peripheral neuropathy (unspecified)
359.1 Muscular dystrophy
379.91 Pain in or around eye
381.4 Ottis Media, unspecified
381.6^ Obstruction/Eustachia
^Fifth digit
0 = Unspecified 1 = Osseous Obstruction 2 = Intrinsic Cartilaginous 3 = Extrinsic Cartilaginous
388.70 Earache
401.9 High blood pressure, hypertension
461.0 Maxillary sinusitis (acute)
461.1 Frontal sinusitis (acute)
461.2 Ethmoidal sinusitis (acute)
461.3 Sphenoidal sinusitis (acute)
472.0 Rhinitis, chronic
473.0 Maxillary sinusitis (chronic)
473.1 Frontal sinusitis (chronic)
473.2 Ethmoidal sinusitis (chronic)
473.3 Sphenoidal sinusitis (chronic)
480 Pneumonia
493.0 Asthma, allergic
493.9 Asthma, bronchial
524.60 Temporomandibular joint disorder (arthralgia/pain)
625.2 Hot flashes
625.3 Menstrual pain, dysmenorrhea
714.0 Rheumatoid arthritis
715.05 Osteoarthritis, Pelvis
716.9** Arthritis (Arthropathies)
716.95 Inflammation of Pelvis
718.0 Meniscus Tear, chronic
718.50 Ankylosis
718.51 Ankylosis, shoulder
718.52 Ankylosis, upper arm
718.53 Ankylosis, forearm
718.54 Ankylosis, hand
718.55 Ankylosis, lower leg
718.56 Ankylosis, ankle, foot
719.0 Joint Swelling
719.4 Pain in the joint
719.5** Stiffness of joint
720.0 Ankylosing Spondylitis
720.2 Sacrolitis
720.9 spondylitis, thoracic
721.9 Arthritis, degenerative, hypertrophic
722.2 IVD prolapse, protrusion, herniation, rupture
722.4 Cervical Disc degeneration
722.51 Thoracic Disc degeneration
722.52 Lumbar Disc Degeneration
723.0 Spinal stenosis, cervical region
723.1 Cervicalgia (pain in neck)
723.2 Cervicocranial Syndrome, upper neck pain
723.3 Cervicobrachial Syndrome
723.4 Cervical radiculitis, brachial neuralgia
723.5 Stiff neck torticollis (contracture of neck)
723.9 Unspecified musculoskeletal disorders and symptoms referable to the neck
724.02 Lumbar stenosis
724.1 Pain in Thoracic Spine
724.2 Low back pain (Lumbago)
724.3 Sciatica
724.4 Radiculitis
724.5 Backache, unspecified, postural
724.6 Disorders of Sacrum, ankylosis of sacrum
724.8 Back stiffness, facet syndrome
726.0 Frozen shoulder
726.10 Rotator cuff syndrome of shoulder – unspecified
726.32 Lateral epicondylitis (Tennis elbow, Golfer’s elbow)
726.90 Tendinitis
728.2 Muscular wasting or atrophy
728.4 Laxity of Ligaments
728.5 Hypermobility Syndrome
728.85 Muscle Spasms
728.9 Weak muscle
729.1 Myalgia and Myositis unspecified;
729.2 Radiculapathy (nerve compression)
729.5 Pain in limb(sore arms/wrist/leg/sole of foot)
733.00 osteoporosis
733.90 Pain in bone – Unspecified
736.81 Short leg – Acquired
737.2 Lordosis, acquired, postural
737.9 Curvature of the spine, acquired
738.2 Acquired Deformity of Neck
738.6 Acquired deformity of the pelvis
739.1 Segmental dysfunction, cervical
739.2 Segmental dysfunction, thoracic
739.3 Segmental dysfunction, lumbar
739.4 Segmental dysfunction, sacrum
739.5 Segmental dysfunction, Pelvis
739.9 Curvature, acquired
741.1 Spina bifida, cervical
741.2 Spinabifida, thoracid
741.3 Spinabifida, lumbar
754.2 Scoliosis, congenital
755.30 Short leg, congenital
756.13 Absence of vertebrae, congenital
756.15 Fusion of spine, congenital
756.2 Cervical Rib
780.4 Dizziness, Vertigo
780.50 Sleep disturbance
780.7 Fatigue
781.2 Abnormality of gait
782.0 Sensitive skin
782.3 Edema
784.0 Headache, facial pain (vascular)
786.51 Midsternal Chest Pain
786.52 Painful Respiration
786.59 Musculoskeletal Chest Pain
787.1 Heartburn
840.* Sprains and strains of shoulder and upper arm
840.0 Acromioclavicular (joint) (ligament)
840.1 Coracoclavicular
840.2 Coracohumeral (muscle) (ligament)
840.3 Infraspinatus (muscle) (tendon)
840.4 Rotator Cuff (capsule)
840.5 Subscapularis (muscle)
840.8 Other specified sites of shoulder and upper arm
840.9 Unspecified site of shoulder and upper arm
841.* Sprains and strains of elbow and forearm
841.0 Radial collateral ligament
841.1 Ulnar collateral ligament
841.2 Radiohumeral (joint)
841.3 Ulnohumeral (joint)
841.8 Other specified sites of elbow and forearm
841.9 Unspecified site of elbow and forearm
842.0* Sprains and strains of the wrist 842.0 Unspecified site
842.1 Carpal (joint)
842.2 Radiocarpal (joint) (ligament)
842.9 Other – Radioulnar joint, distal
842.1* Sprains and strains of the hand
842.10 Unspecified site
842.11 Carpometacarpal (joint)
842.12 Metacarpophalangeal (joint)
842.13 Interphalangeal (joint)
842.19 Other – Midcarpal (joint)
843.* Sprains /strains of hip and thigh 843.0 Iliofemoral( ligament)
843.1 Ischiocapsular (ligament)
843.8 Other specified sites, hip/thigh
843.9 Unspecified site of hip and thigh
844.* Sprains/strains of knee and leg
844.0 Lateral collateral ligament: knee
844.1 Medial collateral ligament, knee
844.2 Cruciate ligament of knee
844.3 Tibiofibular (joint) (ligament), superior
844.8 Other specified sites of knee/leg
844.9 Unspecified site of knee and leg
845.0* Sprains and strains of ankle
845.00 Unspecified site
845.01 Deltoid ( ligament), ankle
845.02 Calcaneofibular (ligament)
845.03 Tibiofibular (ligament), distal
845.09 Other
845.1* Sprains and strains of foot
845.10 Unspecified site
845.11 Tarsometatarsal (joint) (ligament)
845.12 Metatarsophalangeal (joint)
845.13 Interphalangeal (joint), toe
845.19 Other
846.* Sprains/strains of sacroiliac
846.0 Lumbosacral (joint) (ligament)
846.1 Sacroiliac ligament
846.2 Sacrospinatus (ligament)
846.3 Sacrotuberous (ligament)
846.8 Other specified sites of sacroiliac region
846.9 unspecified site of sacroiliac region
847.* Sprains/strains of other and unspecified parts of back
847.0 Neck: Anterior longitudinal (ligament), cervical Atlanto-axial (joints) Atlanto-occipital (joints) Whiplash injury
847.1 Thoracic
847.2 Lumbar
847.3 Sacrum
847.4 Coccyx
847.9 Unspecified site of back
848* Other and ill defined sprains and strains
848.0 Septal cartilage of nose
848.1 Jaw
848.2 Thyroid region
848.3 Ribs
848.5 Pelvis
848.8 Other specified sites of sprains/strains
848.9 Unspecified site of sprain/srain
848.4* Sternum
848.40 Unspecified site
848.41 Sternoclavicular (joint) (ligament)
848.42 Chondrosternal (joint)
848.49 Other – Xiphoid cartilage

** Fifth Digit Instructions
If the place for the fifth digit of a code has a space with a double asterisk (**) in it, refer back to this page for the selection of the appropriate fifth digit.
0 Site unspecified 5 Pelvic region & thigh
1 Shoulder region 6 Lower Leg
2 Upper arm 7 Ankle and foot
3 Forearm 8 Other specified sites
4 Hand 9 Multiple sites
The use of 0, 8 or 9 may require further documentation.


Symptom /Pain Codes – may be allowed in some states and some plans to use these codes without a Physicians Prescription:

Shoulder Pain  719.41

Upper Arm Pain   719.42

Forearm Pain  719.43

Hand Pain   719.44

Pelvis and Thigh Pain 719.45

Lower leg Pain 719.46

Ankle/Foot Pain 719.47

TMJ – 524.62

Neck Pain 723.1

Thoracic spine pain 724.1

Intecostal muscle pain 786.59

Lumbar spine pain 724.2

Sciatica   724.3

Back Pain  724.5

Sacroiliac pain 724.6

Myalgia 729.1

Spasm 728.85

Myositis  728.81

Headache (face pain)   784.0

Tension headache  307.81

Cluster headache 346.2

Migraine 346.9


ICD-9 codes are changing to ICD-10 codes in Oct 2015.

The Dark Side of Massage Insurance Billing

I know I am always talking about massage insurance billing and how it is one of the things that has allowed me to stay in business now since 1989, but there is the other massageinsurancebillingdarksideside of billing insurance: The headaches with insurance companies, healthcare changes, working with doctors/lawyers and things like how clients deal with their health issues.   I do talk about them in my book Insurance Billing 101 for Massage Therapists, but I want to expand on that info here now.

It has always been a mixed blessing for me as you can see from this editorial Massage Insurance Billing (PDF) I wrote on it in 2005 for Massage Magazine.

The first challenges are really all of the hoops you need to jump through when working with insurance companies.  You are really subject to their rules and regulations along with the benefits of each plan.  You have to always be on top of what you need to be doing.  They change their plans/rules as often as they wish and you are often left trying to figure it out on your own.   Things in healthcare are constantly changing with HIPAA laws, billing forms and knowing what you need to do to get paid.

As a provider for health insurance companies here in WA, the insurance companies are constantly lowering their allowable fees (cutting our pay!) and reducing benefits in their plans. They are also doing things like requiring pre-authorization for massage services according to what they have found to be medically necessary but they haven’t really told us how they determine this.   In the beginning of billing health insurance which was around 2000 or so, the insurance companies paid between $60 an hour (4 units of massage) to $120 or more for an hour session.  It is now between $57 and $67 an hour.    That is much less than what I charge my cash clients.  I also have had to raise my fees for cash clients in order to still make the same amount without having to work more per hour.

Some massage therapists often envision that getting into insurance billing is like getting into bed with the devil.  The insurance companies are seen as evil parts of society.  Insurance companies are about profit, greed and money and are not about HEALTH, healing or being healthy.

I also have been seeing more people who won’t come in for massage unless their insurance is paying.  People have become almost dependent on insurance paying.   It has become more of a right here in WA.   People who use their insurance also have a tendency to take it for granted.  They are often the first people to cancel in the last minute or not show because they know that the insurance company is supposed to pay and they don’t know that a massage therapist can not bill the insurance company  for a missed appointment.   You can set cancellation policies around this too and have the client pay for the missed appointment.

People will come in saying I have 16 visits a year and I just want to get massage but often don’t realize that it has to be medically necessary.  It has to be prescribed by a physician and the sessions have to show improvement.  If massage isn’t working, I send them back to their doctors.   Many would just prefer to keep getting massage.

It is also a mixed blessing taking insurance when clients begin to count on their insurance to pay because it somehow makes a massage session more around fixing the client.  While we are taught to fix and know how to fix things that have gone haywire in the musculo-skeletal system, often there is a deeper part of healing that goes beyond fixing that massage can address.  Often the real work is in being present for the client and following the ‘path’ of their illness/disorder (Pathology).   But the insurance companies/doctors/lawyers only want to know if the client is ‘fixed’.  It ties us deeper into that part of us that Loves to fix and Loves to feel powerful when we can fix.  Clients will often be seen wanting us to ‘fix’ them, when in reality they are the only one who can fix themselves.

Insurance companies are also closing their provider lists here meaning even if you wanted to bill, you can’t unless you are already a provider.  They are saying that there are too many massage therapists for the number of patients that they have.  Some of the lists have been closed for years even though many massage therapists have left their networks and/or gone out of business.

With the new HIPAA laws and the many changes occurring in healthcare, there is a larger movement towards being an “evidence based profession”.  The insurance companies definitely want that – it helps them to be more profitable as well as get people better faster hopefully.   (But I still don’t really understand massage research and all of that, although I have tried!)

So why do I persist in all of this insurance billing crapola?

Yes it has allowed me to stay in business for over 25 years but I have also gotten to work with many injuries and conditions that I would have never seen really because people who are seriously hurt or sick may not have the funds to get the help they do need.

What I keep hanging onto is the idea that massage could be mainstream medicine.   Could it be the first line of treatment in most diseases/conditions like:

  • Headaches – removing the need for heavy drugs
  • Carpal Tunnel syndrome – reducing the need for surgery
  • Fibromyalgia – reducing the need for drugs, loss of work etc.
  • Depression/Anxiety  – reduce or eliminate the need for drugs and help people really have better lives
  • Back/Neck Pain – reduce drugs and surgery


What keeps me hanging on is hearing things from major players in the world of massage insurance billing:

Deborah Senn, has told me in person, that the ACA should help us here in WA although I have yet to see how.  Deborah Senn was instrumental in getting massage accepted here by the insurance companies back in 1996 with the creation of the Every Category Law that now reads really closely to the 2706 section of the ACA.

I also heard John Weeks of the Academic Consortium for Complementary & Alternative Health Care (ACCAH) speak at a conference with the Alliance for Massage Education in 2012 and the one thing that he said I found most interesting:  “There is Power in Numbers” meaning that there are over 300,000 MT’s in the US and then you can also count on their clients who love massage.  Could it truly work that way?  Could massage therapists have an impact on the level of care patients get?  Could massage ever be the way to put the HEALTH back into Healthcare?

I may just be delusional also!  It may not ever happen in my lifetime….But….until then,  you might want to just start learning the ropes on how to bill insurance and that is exactly why I have written this book ” Insurance Billing 101 for Massage Therapists”

 Massage Insurance Billing

Will billing insurance help your business be more profitable?


Massage Insurance Billing FormBilling insurance for massage may be one of many ways to help make your business more profitable.   If you need more clients as you are building your business, taking a few insurance clients here and there may help but you will need to figure that out from a business standpoint.  Will it help make your business more profitable?  To figure that out, you will need to know what your cost per client is.

I have always used this basic formula:

Cost per client formula:

  1. Compute your office overhead for a month:

You can take the last 12 months and divide by 12. If you haven’t been working for a year, you can estimate using numbers from the time you have worked.

Salary/needed income $4000
Rent $600
Other salaries
Office expenses $150
Office Supplies $50
Marketing $200
Total Expenses per month $5000


  1. Compute the number of patients for the month. You can use last years patients divided by 12 or estimate the number for this year.

Sample:   15 clients per week x 4.2 weeks/mo =  63 clients per month

  1. Cost per patient = Total monthly expenses____ divided by Total monthly patient visits

Sample:  $5,000 ¸ 63 = $79.00
This is what your cost per patient is.

  1. Evaluate

If you expect the number of clients to go up per month by  21 (5 per week) your cost per client will go down.

$5000 ¸ 84 =59.52

$59.52 will be your new cost per client.

What is the amount that the insurance company will be paying you?

Less than that or more than that?

Will it be worth it to take on new clients at that expected rate?

Will you get too many clients that you will have to hire office support to do the extra work involved?  Hiring someone will increase your expenses and increase the cost per client.

The thing is figuring out what insurance companies might pay you.  In most states you can accept workers compensation.  You will have to do some research and find the workers compensation website and then find out If you can be a provider for them and then find out what their fee schedule is.  It should be public knowledge.  While you are on their site also look for what you need to do to become a provider.  Many states will also offer classes in how to bill worker’s compensation.

You may also be able to bill for car accidents (motor vehicle collision (MVC) is the new term!)  You will need to find out if you are able to bill for car accidents in your state.  I would start with contacting your local AMTA chapter.  If they do not know, then you will just have to ask other therapists or ask an attorney who specializes in  MVC’s.  Many attorneys are always looking for providers who they can refer their clients to.

So once you get an idea of what they will pay you can go through the formula and calculate your new cost per client and see if that would make your business more profitable.

Cost Per Client Worksheet  (PDF)   Download this worksheet to help you figure out your cost per client!

The ACA, aka Obamacare, and Massage therapists : 2706 – It's the Law!

The Affordable Care Act (yes it is the same thing as Obamacare) is starting to come into effect.  Oct 1, 2013,  was the opening of the States insurance exchange market which is where low income people can find insurance plans to fit their needs and budgets.   The massage profession should have been working on getting massage into these plans and all plans for that matter as the ACA has sections that make it so.  2706 is the law now.  How and if it is implemented is another story.

The Integrative Healthcare Policy Consortium (IHPC) has hired Deborah Senn (WA States past insurance commissioner who brought WA MT the Every Category Law which allows MT, ND’s and Acupuncturists to bill insurance)  to work on the implementation in each state.  The IHPC has invited many groups to assist in the process.  The American Massage Therapy Association is listed as one of the groups involved in the process.

In my opinion, AMTA is the most likely group to help get this implemented in each state if possible.   Some of the state chapters already have lobbyists and Government Relations Committees that might already have some sort of relationship with the Office of the Insurance Commissioner or other politicians.  They have the ability to connect with local members in many ways to get the word out and to work together to help each other through the many challenges of working with insurance companies.

The thing really is do we as a profession want to get into healthcare on a whole.

The Down Side of  Billing Insurance

Being in WA State, I have been a contracted provider with health insurance companies since about 2000.  In the beginning, the pay was more than fair (above $95 per hour) and billing was fairly straight forward.  Using www.officeally.com has made the billing process really easy.  It is a free electronic billing service.  The bills are paid usually within a few weeks at most for a clean claim.   Credentialing is done through www.onehealthport.com Provider Source which was a big nightmare for me when I actually lost my credentialing with one insurance company due to many errors in the process.  I was not even warned that I was losing my credentialing.  A client told me!   The biggest problem is that now the provider lists are closed and also the fees have been reduced significantly for most of the major companies meaning I have to do more massage to make the same money and that is something I wasn’t planning on in this stage of my career.  (25 years – My plan was to start slowing down and work less, Play more!)

So with that in mind, why do I still support MT being able to bill insurance companies which also means working with doctors.   I still have this obscure dream that massage could be the first response for many conditions – headaches, fibromyalgia,  carpal tunnel syndrome, herniated discs, back/neck pain etc.   Could massage replace the high priced drugs and become the main treatment protocol for things like these?   What would it take to make that happen?

What it would take would be having a more organized and supportive organization that could stand up for us in the face of low reimbursement fees and closed lists.  What it would take is having a strong network of Massage therapists that will help each other stay up on billing procedures and the many challenges of being a provider.  What it would take is having a unified profession.

There is Power in Numbers

The one thing that gave me some hope was something that I heard last year (2012 AFMTE Conference) was John Weeks ( from www.theintegratorblog.com who is very instrumental in the changes in healthcare for complementary therapies) said :  “There is Power in Numbers” .  Could all 300,000 or so massage therapists AND their many clients make a difference in getting massage covered by healthcare?

Then there is also this stat from AMTA:
From  https://www.amtamassage.org/articles/2/PressRelease/detail/2545

AMTA Stats


The people want coverage!

Would clients come more often when they have pain issues?  Would massage therapists have more clients and not be struggling so much as they are now in general?  Could we ever get insurance companies to pay us what we are worth (at least pay what we charge our cash clients)?

Insurance will only cover things that are medically necessary meaning you will need a prescription from a doctor.  It will only usually cover a certain number of sessions.  In WA on average it is about 16 -20 sessions.   You will not be forced into taking insurance.  Not everyone uses their insurance all the time.   Insurance plans do not cover maintenance massage meaning people can not just come in because they want a massage.  It is only for pain and medical conditions in which massage can help improve the condition!   (That is the way it works in WA now anyways!  Who knows really what other insurance companies will do.)


So get the Facts before you react.

FAQ’s from IHPC

FAQ’s on 2706 (PDF) from IHPC

Implementation FAQ’s from CMS.gov

 Watch this from Deborah Senn


So are you interested?  What are your concerns?  What are your questions?