Article - Billing and Coding: Chiropractic Services (A56273)

CMS National Coverage PolicyN/AArticle TextThis 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 ManualChapter 15 Covered Medical and Other Health Services: 30.5 Chiropractors 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 Insurance240 Chiropractic Services - General240.1.1 Manual Manipulation240.1.2 Subluxation May Be Demonstrated by X-Ray or Physicians Exam240.1.3 Necessity for Treatment240.1.4 Location of Subluxation240.1.5 Treatment ParametersPublication 100-04 Medicare Claims Processing ManualChapter 12 Physicians/Nonphysician Practitioners220 - Chiropractic ServicesChapter 23 Fee Schedule Administration and Coding Requirements20.9.1.1 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 InformationDocumentation requirementsDocumentation 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 GuidelinesClaims 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 GuidelinesThe 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.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 ServicePlace of ServiceProcedure CodeFailure 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.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.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 counselingMedicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage, and abdomen.Request for ReviewWhen requesting a review, submit documentation that supports the medical necessity of the denied service.