Massage vs. Manual Therapy

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Greetings, friends and colleagues. It’s Sam Collins, your coding and billing expert for Chiropractic, ChiroSecure. And of course you, our friends, we’re here today to have a topic. That’s one that’s come up quite a bit because there’s always some issues with these codes and it’s what is the difference?

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between massage and manual therapy? 97124, 97140. How is it documented? What is really the difference? Let’s go to the slides. Let’s take a look at this and see what we’re looking at when it comes to massage versus manual therapy. Now, when you take a look at the slides, here would be my question to you.

As a provider, if you see these two pictures, would you be able to identify which of these services is a massage? Or which is manual therapy. In fact, there is really where the confusion I think comes in is because often providers are confused. When does it determine as manual therapy? What does that mean comparative to massage?

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Because if you look at how it’s being done, they look very similar. And of course, this is part of the confusion when it comes to CPT. Cause you’ll notice, and we’ve done a class on this with you. where we talked about the difference between exercise and therapeutic activities. Massage and manual therapy can fit within that as well, because let’s look at them.

What is massage versus manual therapy? It says massage is the use of rhythmically applied pressure to the skin and soft tissues of the body. So in the definition, effleurage, petrissage, depotment, so stroking, compression, percussion, things of that nature. Okay, that seems okay, but don’t those pictures look like both of those could be that?

What is manual therapy? Manual therapy techniques include soft tissue mobilization, myofascial release, strain counter strain, muscle energy, but also could be joint mobilizations and manipulations. And here’s where things differ a bit. Realize that manual therapy encompasses a lot of things. Not just the soft tissue work.

It could include manual traction by that matter. Manual lymphatic drainage. But for I think the purposes most often chiropractors are looking at is they’re doing kind of the deep tissue work. So can massage be deep tissue? I think so. Really where I think you want to look at is what is the outcome?

How do I make a differentiation between the two? Really, it comes down to what are the goals? What are the purposes? And though the techniques will vary a little bit, there’s some similarities. What are the goals? What is the purpose of my massage therapy? Or what is the purpose of my manual therapy? So massage therapy generally is geared towards promoting physical and mental relaxation.

Just put the person at ease. They’re very acute, very tense, a lot of pent up anxiety, if you will. Certainly massage can help that. Obviously though, what about an area that has A fair amount of muscle spasm or tension, that certainly can be the case. So massage, I would say, falls into relaxation in a very broad sense.

Manual therapy is going to have a different goal, though. Now, it’s not that manual therapy isn’t very similar to massage, but the goals of manual therapy are different in that it’s looking to reduce pain. You’re going to say Sam, Is it massage reducing pain? Yes, but it’s more about function, not relaxation.

By reducing pain to increase mobility of the joint. Let’s take a look. What is massage? The techniques are almost all the types you can think of. Friction, gliding, stroking, and all those factors could include some percussion. So be careful if you’re using one of these percussion devices.

I would certainly say that could fall under massage, but be very careful. Make sure you show that it’s adequately skilled. It’s not just a staff member running it up and down. It’s got to be a skilled with purpose. So it says here, massages of pattern and purposeful soft tissue manipulation accomplished by the use of the digits, hands, forearms, elbows, knees, feet, or the use of emollients, liniments, cold handheld tools.

It can include everything and it’s pressure movements on muscles and soft tissues to promote relaxation. So the goal, relaxation, stress, Circulation. Maybe a little bit of flexibility. Yeah, because the muscle is more relaxed. It’s more generalized body work and usually over larger parts.

Certainly fits within a plan of care when a person first comes in very acute. Makes a lot of sense. Now, massage really describes a separate and distinct service. Now, what we have to be careful of is making sure that it is separate and distinct. We’ll get more into that as we go on. It says here, massage describes a service that is separate and distinct for those described by manipulation.

It does not involve some joint mobilization or component of that nature. It’s applied to large areas, often crossing several types. It can be used for stimulating soft tissue. That’s the deployment part. The expected outcomes are more general nature. In fact, the patient can tolerate the more, this is what they can tolerate in the acute stage.

Increasing circulation, muscle soreness, tension, anxiety. You get the point. The purpose behind massage is what is Manual Therapy then? Because Manual Therapy is hands on. Manual Therapy techniques consist of, but not limited to, Connective Tissue Massage. Now, that’s a little bit different. That’s going to be much deeper.

Because what you’re looking to do there is break down scar tissue. Literally increasing the Length of that. Joint mobilization could fit in here. So remember, not chiropractic manipulation, but a joint mobilization. Now, from a medical standpoint, this is what a medical provider would use for manipulation.

Chiropractors don’t. We have our own code, but it could fit there. It doesn’t fit for chiros. But that includes manual traction, and that may involve some passive range of motion, soft tissue mobilization, and parts of it is like manipulation and therapeutic massage. You’re going, wait a minute, Sam.

How is this different? Let’s look here. Typically, the goals of manual therapy are to modulate pain. That’s the start, but increase joint range of motion. Reduce and eliminate soft tissue swelling. Inflammation or restriction. Think of, probably, manual therapy is going to fit more of active rehabilitation because you’re trying to change motion or extensibility.

They include muscle relaxation to improve contractile, non contractile tissue extensibility. Meaning ligaments. Manual therapy techniques may be formed on individual symptoms that include limited range of motion, muscle spasm, pain, scar tissue. Think of it more about joint motion or movement extensibility than simply relaxation.

In fact, I think the American Physical Therapy Association, and I won’t say, oh we’re going to follow everything they say, but I think they give a good point to it. It says manual therapy techniques are skilled hand movements and skilled passive movements of joints. Massage generally is not going to include motion, though it might, and intended to improve tissue extensibility.

So the big difference here is when you’re describing the manual therapy you’re doing, it’s usually maybe deeper tissue or style, and then the goal is to increase extensibility, motion, okay? As opposed to massage being more from relaxation, I’d say manual therapy is more muscle rehabilitation. Now the difficulty here for chiropractic, unfortunately, Is what about being paid for it?

If you’re just doing it by itself, non issue. But one thing we have to deal with, remember, according to the CCI edits, ChiroCoding Initiative edits, manual therapy or massage done in the same region as manipulation is considered inclusive, part of the adjustment. So the difficulty here is what if you’re going to do, I don’t know, 15 minutes of massage work or deep tissue work to the neck, followed up by manipulation to the Coding guidelines state the adjustment.

is going to include all of it. In other words, you get paid only for the adjustment. Now, I do not like that. I think that’s completely unreasonable. And by the way, this is one of the reasons osteopaths were a little smarter than us. They included in their manipulation code. extra values to include this work.

And I think chiropractic, because we stuck so closely to the philosophy of chiropractic adjustment, we didn’t think probably further that we probably should increase the value since it was going to be inclusive for all of this. That’s water under the bridge and I don’t want to get too far there.

What I want to talk about is being paid. So take a look. Here’s a sample of a 1500. If you want to be paid, for manual therapy massage. At the end of the day, that’s part of it. We need to do the work, get what’s done for the patient, help them. But also, can we get paid for it? Because, what, I want to do a 30 minute massage?

That’s included in my three minute adjustment? No. Now, here would be my wonder, do they really need a 30 minute massage? Is it that high of value? Now that’s something you have to decide as a practitioner, but let’s talk about being paid. Take a look here. Diagnosis A and B. If you’re familiar, M5412 is radiculopathy cervical.

M7912 is myalgia of the cervical. So we’re indicating this person has radiculopathy and a lot of muscle pain in the cervical region. You’ll notice. We’re putting 9 7 1 2 4 Xs. Now I know obviously Sam Xs. Xs is technically probably the better modifier than the one you’re used to, which is 59. Nonetheless, both work, so I don’t really wanna get too caught up in that.

But technically, X excess is a little better because it indicates a separate region. But notice what we’ve done here, 9 7, 1 2 4 noting Xs. Notice where it’s being applied ab. We’re applying the adjustment. Not to the neck. We’re doing the massage. So this is our way of pointing to clearly demonstrate yes, pay it, because it’s separate, because we’ve pointed the massage to a separate region.

Now you’ll notice M5459 is other specified low back pain, and then the arthritis or Spondylosis of lumbar. You’ll notice 98940 has C and D. This is indicating that the adjustment goes to low back, massage to the neck. Now what you have to be sure of is that do the chart notes match that. Let’s not lie about it.

Don’t adjust and do massage if you’re expected to be paid. You may have visits where you’re going to go, you know what, this patient really needs massage more in the neck than they do because they’re so acute. Maybe we’ll do massage and then add in some adjustments later. This would be the case here, so you’re showing it separate.

This is the difficulty with massage and manual therapy. Now, I’m not anti massage and manual therapy. I just don’t like being paid for a lot of work. One thing I will say to you, and this is something we will do in a future class, what about doing more active care protocols that maybe don’t have to have separate areas?

But nonetheless, there’s places for massage. There’s places for manual therapy, and when you do, make sure you’ve documented what is it I’m doing, where I’m doing it, what’s the purpose, remember the goal is going to set the tone, and of course, the number of minutes. Remember, these are timed codes. Bottom line is, differentiation comes down to what do you document, what do you document.

More than anything, what is the purpose? What is the goal? Think of it along these terms, though, because a lot of people wonder it would appear manual therapy has a higher value. In fact, it’s the opposite. The 2024 relative values, and I know most of you think based on how I even describe manual therapy, it would seem like manual therapy should be worth more.

It does to me, too. But it’s not. Notice here, massage has the higher value. Now I’m not saying let’s pick massage because it has higher value, but what I’m pointing out is, it doesn’t always fit what we think. So realize, the reimbursement for massage is roughly 10 percent higher than would be the reimbursement for manual therapy.

Bottom line, keep it simple. Document the separate distinct services, make sure it’s there and complete. If it’s not a separate area, that’s a problem. But if it is, you’re good. Massage and manual therapy can be integral to a patient’s recovery. But remember, documentation of what happened is going to be what happened.

Not what you thought you did, but what do you document. As always, I’m Sam Collins, the coding and billing expert. Take a look. H. J. Ross, we’re here to help. H. J. Ross does seminars and we give you one on one help. Until next time, my friends, take care.