Billing and Coding: Chiropractic Services

This article provides billing and coding guidelines for Chiropractic services.
Coverage of Chiropractic services is a limited benefit. The coverage is
limited to manual manipulation for the treatment of subluxation. "Subluxation"
is a term used by Chiropractors to describe a spinal vertebra that is out of
position in comparison to the other vertebrae.

Refer to the following Medicare Internet online Manuals (IOMs) for coverage of
Chiropractic services:  
Publication 100-02 Medicare Benefit Policy Manual  
Chapter 15 Covered Medical and Other Health Services:

  *  30.5 Chiropractor's Services
  *  40.4 Definition of Physician /Practitioner.
  *  220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance
  * 240 Chiropractic Services - General
  * 240.1.1 Manual Manipulation
  * 240.1.2 Subluxation May Be Demonstrated by X-Ray or Physician's Exam
  * 240.1.3 Necessity for Treatment
  * 240.1.4 Location of Subluxation
  * 240.1.5 Treatment Parameters

Publication 100-04 Medicare Claims Processing Manual  
Chapter 12 Physicians/Nonphysician Practitioners

  * 220 - Chiropractic Services

Chapter 23 Fee Schedule Administration and Coding Requirements

  * 20.9.1.1 Instructions for Codes with Modifiers (A/B MACs (B) Only)

WPS GHA has further guidance for the physical examination (IOM 100-02
240.1.2)  
PART (Pain, Asymmetry, Range of motion and tissue tone changes)

Pain - Most primary neuromusculoskeletal disorders manifest primarily by a
painful response. Pain and tenderness findings may be identified through one
or more of the following: observation, percussion, palpation, provocation,
etc. Furthermore, pain intensity may be assessed using one or more of the
following: visual analog scales, algometers, pain questionnaires, etc.

Asymmetry/misalignment - Asymmetry/misalignment may be identified on a
sectional or segmental level through one or more of the following: observation
(posture and gait analysis), static palpation for misalignment of vertebral
segments, diagnostic imaging, etc.

Range of motion abnormality - Range of motion abnormalities may be identified
through one or more of the following: motion, palpation, observation, stress
diagnostic imaging, range of motion measurements, etc.

Tissue/Tone texture may be identified through one or more of the following
procedures: observation, palpation, use of instruments, tests for length and
strength etc.

The problem/complaint addressed, and precise level of each subluxation
treated, must be specified in the medical record. The need for an extensive,
prolonged course of treatment should be consistent with the reported diagnosis
and must be clearly documented in the medical record. The level of the
subluxation must be specified on the claim and must be listed as the primary
diagnosis. Refer to ICD-10 Codes that Support Medical Necessity found below
either listed by location (Lumbar) or exact bones (L1, L2, etc.).

**Associated Information**  
 **Documentation requirements**  
Documentation supporting the medical necessity of this item, such as diagnosis
codes, must be submitted with each claim. Claims submitted without diagnosis
codes will be denied as being not medically necessary. Documentation in the
form of progress notes need not be submitted with each claim but be available
upon request.

For Medicare purposes, a chiropractor must place an AT modifier on a claim
when providing active/corrective treatment to treat acute or chronic
subluxation. Claims submitted for Chiropractic Manipulative Treatment (CMT)
CPT codes 98940, 98941, or 98942, (found in Group 1 codes under CPT/HCPCS
Codes) not containing an AT modifier will be considered not medically
necessary.

**Utilization Guidelines**

Claims should be filed by the performing chiropractor. The Physician Fee
Schedule is used when paying for chiropractor services.

Once the maximum therapeutic benefit has been achieved for a given condition,
ongoing maintenance therapy is not considered to be medically necessary under
the Medicare program.

**Coding Guidelines**

  1. The precise level of subluxation must be specified on the claim and must be listed as the primary diagnosis. The neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis.
  2. All claims for chiropractic services must include the following information:  
Date of the initiation of the course of treatment.  
Symptom/condition/Secondary diagnosis code(s)  
Subluxation(s)/Primary diagnosis code(s)  
Date of Service  
Place of Service  
Procedure Code  
Failure to report these items will result in claim denial or delay.  
  
 **Note:** Date of last x-ray is no longer required. Any date placed in item
19 is considered date of last x-ray. It is recommended that providers do not
place any date in item 19 of the CMS-1500 claim form.

  3. Limitation of Liability rules apply: The purpose of the Limitation of Liability provision is to protect the beneficiary from liability in denial cases under certain conditions when services rendered are found to be not reasonable and medically unnecessary.  
  
If the provider uses the AT Modifier and believes a service is likely to be
denied by Medicare as not being medically necessary, the beneficiary must sign
an Advance Beneficiary Notification (ABN) and the GA modifier must be used.

  4. Physician signature for progress notes and reports (handwritten, electronic). Initials if signed over a typed or printed name or accompanied by a signature log or attestation statement.

**Non-Covered Services:**  
All services other than manual manipulation of the spine for treatment of
subluxation of the spine are excluded when ordered or performed by a Doctor of
Chiropractic. Chiropractors are not required to bill these to Medicare.
Chiropractic offices may want to submit charges to Medicare to obtain a denial
necessary for submitting to a secondary insurance carrier. The following are
examples (not an all-inclusive list) of services that, when performed by a
Chiropractor, are excluded from Medicare coverage:  
\- Laboratory tests  
\- X-rays  
\- Office Visits (history and physical)  
\- Physiotherapy  
\- Traction  
\- Supplies  
\- Injections  
\- Drugs  
\- Diagnostic studies including EKGs  
\- Orthopedic devices  
\- Nutritional supplements and counseling

Medicare does not cover chiropractic treatments to extraspinal regions (CPT
98943), which includes the head, upper and lower extremities, rib cage, and
abdomen.

**Request for Review**  
When requesting a review, submit documentation that supports the medical
necessity of the denied service.