Billing and Coding: Chiropractor Services

As Noridian has recently retired the Chiropractic Services LCD, this article
is offered to help guide in the billing, coding and documentation of
chiropractic services, as supplementary to the provisions of the Medicare
Benefit Policy Manual, Chapter 15, Section 30.5, and the Medicare Claims
Processing Manual, Chapter 12, Section 220.

The following information must be documented in the medical record.  

I. History:

  chief complaint including the symptoms present that caused the patient to
seek chiropractic treatment.  
  
II. Present Illness: This can include any of the following as appropriate:

 mechanism of trauma;  
 quality and character of problem/symptoms;  
 intensity of symptoms;  
 frequency of symptoms occurring;  
 location and radiation of symptoms;  
 onset of symptoms;  
 duration of symptoms;  
 aggravating or relieving factors of symptoms;  
 prior interventions, treatments, including medications;  
 secondary complaints; and  
 symptoms causing patient to seek treatment.  
  

III. Family History: If pertinent  
  

IV. Pertinent past health history which may include:  
  
 general health statement  
 prior illness(es)  
 surgical history  
 prior injuries or traumas  
 past hospitalizations (as appropriate)  
 medications  
  

V. Physical examination: Evaluation of musculoskeletal/nervous system through
physical examination to identify:  
  
a. Pain/tenderness evaluated in terms of location, quality and intensity;  
b. Asymmetry/misalignment identified on a sectional or segmental level;  
c. Range of motion abnormality (changes in active, passive and accessory joint
movements resulting in an increase or a decrease of sectional or segmental
mobility); and  
d. Tissue, tone changes in the characteristics of contiguous or associated
soft tissues, including skin, fascia, muscle and ligament.  
  

To demonstrate a subluxation based on physical examination, two of the four
criteria mentioned under physical examination are required, one of which must
be asymmetry/misalignment or range of motion abnormality.  
  
VI. Diagnosis: The primary diagnosis must be subluxation, including the level
of subluxation either so stated or identified by a term descriptive of
subluxation. Such terms may refer either to the condition of the spinal joint
involved or to the direction of position assumed by the particular bone named.  
  

VII. Treatment Plan: The treatment plan should include the following:

 Therapeutic modalities to effect cure or relief (patient education and
exercise training).  
 The level of care that is recommended (the duration and frequency of
visits).  
 Specific goals that are to be achieved with treatment.  
 Objective measures to evaluate treatment effectiveness.  
 Date of initial treatment.

VIII. Subsequent Visits:

The following documentation requirements apply whether the subluxation is
demonstrated by x-ray or by physical examination for subsequent visits:

1\. History:  
Review of chief complaint;

Interval history, and system review if relevant.  
  

2\. Physical exam:  
Exam of area of spine involved in diagnosis;  
Assessment of change in patient condition since last visit;  
Evaluation of treatment effectiveness.  
  
3\. Documentation of treatment given on day of visit.  
  
Medical Necessity of Treatment:  
  

Failure to document that the chiropractic spinal manipulation is reasonable
and necessary may result in denial of claim(s). This requirement may be
fulfilled by indicating the Date of Service as a component of an ordered
sequence of treatments in the treatment plan, i.e. #4 of ten planned
adjustments".

Reasonable and necessary requirements may be additionally fulfilled by a
comparative assessment of clinical treatment goals, compared to the assessment
at the initial visit, and at the conclusion of a course of treatment.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits.
This policy does not take precedence over CCI edits. Please refer to the CCI
for correct coding guidelines and specific applicable code combinations prior
to billing Medicare.  
  
When the documentation does not meet the criteria for the service rendered or
the documentation does not establish the medical necessity for the services,
such services will be denied as not reasonable and necessary.