(Medicare Benefit Policy Manual)

2. Demonstrated by Physical Examination   Evaluation of musculoskeletal/nervous system to identify:   Pain/tenderness evaluated in terms of location, quality, and intensity;   Asymmetry/misalignment identified on a sectional or segmental level;   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  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.   The history recorded in the patient record should include the following:   Symptoms causing patient to seek treatment;   Family history if relevant;  Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);  Mechanism of trauma;   Quality and character of symptoms/problem;   Onset, duration, intensity, frequency, location and radiation of symptoms;   Aggravating or relieving factors; and   Prior interventions, treatments, medications, secondary complaints.   A.  Documentation Requirements: Initial Visit   The following documentation requirements apply whether the subluxation is demonstrated by x- ray or by physical examination:   1. History as stated above.   2. Description of the present illness including:   Mechanism of trauma;   Quality and character of symptoms/problem;   Onset, duration, intensity, frequency, location, and radiation of symptoms;   Aggravating or relieving factors;   Prior interventions, treatments, medications, secondary complaints; and   Symptoms causing patient to seek treatment.   These symptoms must bear a direct relationship to the level of subluxation.  The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc.  Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness.  Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such.  The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited.  A statement on a claim that there is pain is insufficient.  The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.   3. Evaluation of musculoskeletal/nervous system through physical examination.  4. 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.   5. Treatment Plan:  The treatment plan should include the following:   Recommended level of care (duration and frequency of visits);   Specific treatment goals; and   Objective measures to evaluate treatment effectiveness.   6. Date of the initial treatment.   B.  Documentation Requirements:  Subsequent Visits   The following documentation requirements apply whether the subluxation is demonstrated by x- ray or by physical examination:   1. History   Review of chief complaint;   Changes since last visit;  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.  240.1.3 - Necessity for Treatment  (Rev. 23, Issued: 10- 08-04, Effective: 10 -01-04, Implementation: 10- 04-04)  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 patients 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, as described above.   Most spinal joint problems fall into the following categories:    Acute subluxation- A patients 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 patients condition.   Chronic subluxation- A patients 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 so me 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.   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, contracto rs may deny if appropriate after medical review.   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.  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 a nd include a GA (or in rare instances a GZ) modifier on the claim.  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.  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.  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.  240.1.4  Location of Subluxation  (Rev. 1, 10- 01-03) B3-2251.4  The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.  This designation is made in relation to the part of the spine in which the subluxation is identified:   Area of Spine  Names of Vertebrae  Number of Vertebrae  Short Form or Other Name Neck  Occiput  7 Occ, CO   Cervical   C1 thru C7  Atlas   C1  Axis   C2 Back  Dorsal or  12 D1 thru D12   Thoracic   T1 thru T12  Costovertebral   R1 thru R12  Costotransverse   R1 thru R12 Low Back  Lumbar  5 L1 thru L5 Pelvis  IIii, r and 1   I, Si Sacral  Sacrum, Coccyx   S, SC   In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment.   There are two ways in which the level of the subluxation may be specified.  The exact bones may be listed, for example: C5, C6, etc.   The area may suffice if it implies only certain bones such as: Occipito -atlantal (occiput and C1 (atlas)), lumbo- sacral (L5 and Sacrum), sacro -iliac (sacrum and ilium).   Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:  Off-centered   Misalignment  Malpositioning   Spacing -  abnormal, altered, decreased, increased   Incomplete dislocation   Rotation   Listhesis -  antero, postero, retro, lateral, spondylo  Motion -  limited, lost, restricted, flexion, extension, hyper mobility, hypomotility, aberrant   Other terms may be used.  If they are understood clearly to refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.   240.1.5 - Treatment Parameters  (Rev. 23, Issued: 10- 08-04, Effective: 10 -01-04, Implementation: 10- 04-04) B3-2251.5  The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time.  Acute subluxation (e.g., strains or sprains) problems may require a s many as three months of treatment but some require very little treatment.  In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.  Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already set and fibrotic tissue has developed.  This condition may require a longer treatment time, but not with higher frequency.   Some chiropractors have been identified as using an intensive care concept of treatment.  Under this approach multiple daily visits (as many as four or five in a single day) are given in the office or clinic and so- called room or ward fees are charged si nce the patient is confined to bed usually for the day.  The room or ward fees are not covered and reimbursement under Medicare will be limited to not more than one treatment per day.  250 - Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities  (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)  There are several services which, when provided to a hospital or SNF inpatient, are covered under Part B, even though the patient has Part A coverage for the hospital or SNF stay.  Those services are:   Physicians services (including the services of residents and interns in unapproved teaching programs);   Physician assistant services, furnished after December 31, 1990;   Certified nurse -midwife services, as described in 180, furnished after December 31, 1990; and  Qualified clinical psychologist services, as defined in 160, furnished after December 31, 1990;   Screening mammography services;   Screening pap smears and pelvic exams;   Screening glaucoma services;   Influenza, pneumococcal pneumonia, and hepatitis B vaccines and their administrations;   Colorectal screening;   Bone mass measurements; and   Prostate screening;   Pneumococcal and hepatitis B vaccine services must be provided directly or arranged for by the hospital in order to be covered when furnished to a hospital inpatient.  The other services listed are not subject to bundling but, because they are excluded from the statutory definition of inpatient hospital services, may be covered only under Part B.  Payment may be made under Part B to a hospital (or critical access hospital) for certain medical and other health services furnished to its inpatients as provided in Chapter 6, 10 of this manual, Medical and Other Health Services Furnished to Inpatients of Participating Hospitals.