Chiropractic Services  Medical Policy Article

**Abstract:**

Chiropractic manipulative treatment (CMT) is a form of manual treatment to
influence joint and neurophysiological function. This treatment may be
accomplished using a variety of techniques. Medicare covers limited
chiropractic services when performed by a chiropractor who is licensed or
legally authorized to furnish chiropractic services by the State or
jurisdiction in which the services are furnished (CMS Publication 100-01,
Medicare General Information, Eligibility and Entitlement Manual, Chapter 5,
Section 70.6). A chiropractor must also meet uniform minimum standards as set
forth in the CMS Internet-Only Manual (IOM) Publication 100-1, Chapter 5,
Section 70.6. This article restates language directly from the CMS Internet-
Only manuals and if necessary provides clarification to educate providers on
specified Medicare requirements for the diagnosis, treatment, documentation
and billing of chiropractic services.

**Chiropractic Services - Active Treatment: **

_The patient must have a significant health problem in the form of a
neuromusculoskeletal condition necessitating treatment, and the manipulative
services rendered must have a direct therapeutic relationship to the patient
's condition and provide reasonable expectation of recovery or improvement of
function. The patient must have a subluxation of the spine as demonstrated by
x-ray or physical exam._ (CMS Publication 100-02, _Medicare Benefit Policy
Manual_ , Chapter 15, Section 240.1.3).

_Most spinal joint problems fall into the following categories:_

_Acute subluxation - A patient 's condition is considered acute when the
patient is being treated for a new injury, identified by x-ray or physical
exam as specified above. The result of chiropractic manipulation is expected
to be an improvement in, or arrest of progression, of the patient's
condition._

_Chronic subluxation - A patient 's condition is considered chronic when it is
not expected to significantly improve or be resolved with further treatment
(as is the case with an acute condition), but where the continued therapy can
be expected to result in some functional improvement. Once the clinical status
has remained stable for a given condition, without expectation of additional
objective clinical improvements, further manipulative treatment is considered
_maintenance therapy and is not covered. (CMS Publication 100-02, _Medicare
Benefit Policy Manual_ , Chapter 15, Section 240.1.3).

An acute exacerbation is a temporary but marked deterioration of the patient's
condition that is causing significant interference with activities of daily
living due to an acute flare-up of the previously treated condition. The
patient's clinical record must specify the date of occurrence, nature of the
onset, or other pertinent factors that would support the medical necessity of
treatment. As with an acute injury, treatment should result in improvement or
arrest of the deterioration within a reasonable period of time.

_A. Maintenance Therapy_

_Maintenance therapy includes services that seek to prevent disease, promote
health and prolong and enhance the quality of life, or maintain or prevent
deterioration of a chronic condition. When further clinical improvement cannot
reasonably be expected from continuous ongoing care, and the chiropractic
treatment becomes supportive rather than corrective in nature, the treatment
is then considered maintenance therapy._ (CMS Publication 100-02, _Medicare
Benefit Policy Manual_ , Chapter 15, Section 240.1.3A)

_B. Contraindications_

_Dynamic thrust is the therapeutic force or maneuver delivered by the
physician during manipulation in the anatomic region of involvement. A
relative contraindication is a condition that adds significant risk of injury
to the patient from dynamic thrust, but does not rule out the use of dynamic
thrust. The doctor should discuss this risk with the patient and record this
in the chart. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter
15, Section 240.1.3B)_

_The following are **relative contraindications** to Dynamic thrust:_

_Articular hyper mobility and circumstances where the stability of the joint
is uncertain;_

_Severe demineralization of bone;_

_Benign bone tumors (spine);_

_Bleeding disorders and anticoagulant therapy;_

_and Radiculopathy with progressive neurological signs._ (CMS Publication
100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section 240.1.3B).

_Dynamic thrust is absolutely contraindicated near the site of demonstrated
subluxation and proposed manipulation in the following:_

_Acute arthropathies characterized by acute inflammation and ligamentous
laxity and anatomic subluxation or dislocation; including acute rheumatoid
arthritis and ankylosing spondylitis;_

_Acute fractures and dislocations or healed fractures and dislocations with
signs of instability;_

_An unstable os odontoideum;_

_Malignancies that involve the vertebral column;_

_Infection of bones or joints of the vertebral column;_

_Signs and symptoms of myelopathy or cauda equina syndrome;_

_For cervical spinal manipulations, vertebrobasilar insufficiency syndrome;
and A significant major artery aneurysm near the proposed manipulation._ (CMS
Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section
240.1.3B).

_The term "physician" under Part B includes a chiropractor who meets the
specified qualifying requirements set forth in 30.5 but only for treatment by
means of manual manipulation of the spine to correct a subluxation._ (CMS
Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section
240)

_Coverage extends only to treatment by means of manual manipulation of the
spine to correct a subluxation provided such treatment is legal in the State
where performed. All other services furnished or ordered by chiropractors are
not covered._ (CMS Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15, Section 30.5)

_No other diagnostic or therapeutic service furnished by a chiropractor or
under the chiropractor 's order is covered. This means that if a chiropractor
orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray
or other diagnostic test, can be used for claims processing purposes, but
Medicare coverage and payment are not available for those services. This
prohibition does not affect the coverage of x-rays or other diagnostic tests
furnished by other practitioners under the program. For example, an x-ray or
any diagnostic test taken for the purpose of determining or demonstrating the
existence of a subluxation of the spine is a diagnostic x-ray test covered
under 1861(s)(3) of the Act if ordered, taken, and interpreted by a physician
who is a doctor of medicine or osteopathy._ (CMS Publication 100-02, _Medicare
Benefit Policy Manual_ , Chapter 15, Section 240.1.1)

The mere statement or diagnosis of "pain" is not sufficient to support medical
necessity for the treatments. The precise level(s) of the subluxation(s) must
be specified by the chiropractor to substantiate a claim for manipulation of
each spinal region(s). There are five spinal regions addressed: cervical
region (atlanto-occipital joint), thoracic region
(costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-
iliac joint) and sacral region (ref. CPT Professional Edition 2017 p. 672).

Medicare does not cover chiropractic treatments to extraspinal regions (CPT
98943). The five extraspinal regions are: head (including temporomandibular
joint, excluding atlanto-occipital) region; lower extremities; upper
extremities; rib cage (excluding costotransverse and costovertebral joints)
and abdomen (CPT Assistant Nov 98:38).

_For Medicare purposes, a chiropractor **must** place an AT modifier on a
claim when providing active/corrective treatment to treat acute or chronic
subluxation. However the presence of the AT modifier may not in all instances
indicate that the service is reasonable and necessary. As always, contractors
may deny if appropriate after medical review._ (CMS Publication 100-02,
_Medicare Benefit Policy Manual_ , Chapter 15, Section 240.1.3). Modifier AT
must only be used when the chiropractic manipulation is "reasonable and
necessary" as defined by national policy. Modifier AT must not be used when
maintenance therapy has been performed. The need for a prolonged course of
treatment should be appropriate to the reported procedure code(s) and medical
necessity must be documented clearly in the medical record.  
  

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed.

_Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines:_

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
_Medicare Claims Processing Manual,_ Chapter 30, for complete instructions.

**Specific coding guidelines for this policy:**

The precise level of the subluxation must be listed.

The date of the initial treatment or date of exacerbation of the existing
condition must be entered in Item 14 of the CMS-1500 form or the electronic
equivalent.

If using an x-ray as documentation of the subluxation, the date of the x-ray
(or existing MRI or CT scan) must be entered in Item 19 of the CMS-1500 form
or the electronic equivalent.

If an authorized ordering practitioner orders the x-ray, then he/she should
enter his/her name in Item 17 of the CMS-1500 form and his/her own NPI number
in Item 17a of the CMS-1500 form, or the electronic equivalent, as the
ordering physician.

The HCPCS modifier AT (acute treatment) **must** be appended to the
chiropractic manipulation code to indicate the manipulation was for medically
necessary and reasonable treatment of an acute subluxation or chronic
subluxation as defined in national policy and the LCD.

_The AT modifier must not be placed on the claim when maintenance therapy has
been provided. Claims without the AT modifier will be considered as
maintenance therapy and denied. Chiropractors who give or receive from
beneficiaries an ABN shall follow the instructions in Pub. 100-04, Medicare
Claims Processing Manual, chapter 23, section 20.9.1.1 and include a GA (or in
rare instances a GZ) modifier on the claim._ (CMS Publication 100-02,
_Medicare Benefit Policy Manual,_ Chapter 15: Section 240.1.3)

**For claims submitted to the Part B MAC:** All services/procedures performed
on the same day for the same beneficiary by the physician/provider should be
billed on the same claim.