evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractors 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.  Manual devices (i.e., those that are hand -held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine.  However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.   Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation.  However, an x-ray may be used for this purpose if the chiropractor so chooses.  The word correction may be used in lieu of treatment.  Also, a number of different terms composed of the following words may be used to describe manual manipulation as defined above:   Spine or spinal adjustment by manual means;    Spine or spinal manipulation;    Manual adjustment; and    Vertebral manipulation or adjustment.   In any case in which the term(s) used to describe the service performed suggests that it may not have been treatment by means of manual manipulation, the A/B MAC (B) analyst refers the claim for professional review and interpretation.   240.1.2 - Subluxation May Be Demonstrated by X -Ray or Physicians Exam (Rev. 1, 10- 01-03) B3-2251.2  Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.
(Medicare Benefit Policy Manual)
Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.   A subluxation may be demonstrated by an x- ray or by physical examination, as described below.  1. Demonstrated by X -Ray  An x -ray may be used to document subluxation.  The x- ray must have been taken at a time reasonably proximate to the initiation of a course of treatment.  Unless more specific x-ray evidence is warranted, an x -ray is considered reasonably proximate if it wa s taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment.  In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiarys health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.  A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.   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
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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;
(Medicare Benefit Policy Manual)
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.   Payment may be made under Part B for certain medical and other health services if the beneficiary is an inpatient of a skilled nursing facility (SNF) as provided in chapter 8,  70ff of this manual.   260 - Ambulatory Surgical Center Services  (Rev. 77; Issued: 08- 29-07; Effective: 01 -01-08; Implementation:  01- 07-08)  Facility services furnished by ambulatory surgical centers (ASCs) in connection with certain surgical procedures are covered under Part B.  To receive coverage of and payment for its services under this provision, a facility must be certified as meeting the requirements for an ASC and enter into a written agreement with CMS.  Medicare periodically updates the list of covered procedures and related payment amounts through release of regulations and change requests.  The ASC must accept Medicares payment for such procedures as payment in full with respect to those services defined as ASC facility services.   Where services are performed in an ASC, the physician and others who perform covered services may also be paid for his/her professional services; however, the professional rate is then adjusted since the ASC incurs the facility costs.
(Medicare Benefit Policy Manual)
Where services are performed in an ASC, the physician and others who perform covered services may also be paid for his/her professional services; however, the professional rate is then adjusted since the ASC incurs the facility costs.   260.1 - Definition of Ambulatory Surgical Center (ASC)  (Rev. 104; Issued:  03- 13-09; Effective Date:  04 -01-09; Implementation Date:  04-06-09)  An ASC for purposes of this benefit is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. It enters into an agreement with CMS to do so.  An ASC is either independent (i.e., not a part of a provider of services or any other facility), or operated by a hospital (i.e., under the common ownership, licensure, or control of a hospital).  To be covered as an ASC operated by a hospital, a facility elects to do so, and continues to be so covered unles s CMS determines there is good cause to do otherwise.  This provision is intended to prohibit such an entity from switching from one payment method to another to maximize its revenues (47 FR 34082, 34099, Aug. 5, 1982).  For other general conditions and re quirements, see 42 CFR 416.25- 416.49. If the hospital based surgery center is certified as an ASC it is considered an ASC and is subject to rules for ASCs.  Related survey requirements are published in the State Operations Manual, Pub. 100- 07, Appendix L.  Claims processing and payment requirements for ASCs are published in Pub. 100- 04, the Medicare Claims Processing Manual, chapter 14.
(Medicare Benefit Policy Manual)
If a hospital based surgery center is not certified as an ASC it continues under the program as part of the hospital. In that case the applicable hospital outpatient payment rules apply.  This is the outpatient prospective payment system (OPPS), for most hospitals, or may be provisions for hospitals excluded from OPPS.  See Pub.100- 04, the Medicare Claims Processing Manual, chapter 4, for billing and payment requirements for hospital outpatient services.  Indian Health Service (IHS) hospital outpatient departments are not certified as separate ASC entities.  The ASC indication merely means that CMS approved them to bill for ASC services and be paid based on the ASC rates for services on the ASC list.  In order to bill for ASC services, the hospital outpatient department must meet the conditions of participation for hospitals defined at 42 CFR, Part 482.  See Pub. 100- 04, the Medicare Claims Processing Manual, chapter 19, sections 40.2.1, and 80.9 for more information on IHS hospital outpatient departments billing for ASC services.   260.2 - Ambulatory Surgical Center Services  (Rev. 77; Issued: 08- 29-07; Effective: 01 -01-08; Implementation:  01- 07-08)
(Medicare Benefit Policy Manual)
260.2 - Ambulatory Surgical Center Services  (Rev. 77; Issued: 08- 29-07; Effective: 01 -01-08; Implementation:  01- 07-08)  The ASC facility services are services furnished in an ASC in connection with a covered surgical procedure that are otherwise covered if furnished on an inpatient or outpatient basis in a hospital in connection with that procedure.  Not included in the def inition of facility services are medical and other health services, even though furnished within the ASC, which are covered under other portions of the Medicare program, or not furnished in connection with covered surgical procedures.  This distinction bet ween covered ASC facility services and services which are not covered ASC facility services is important, since the facility payment rate includes only the covered ASC facility services.  Services, which are not covered ASC facility services such as physic ians services and prosthetic devices other than intraocular lenses (IOLs), may be covered and billable under other Medicare provisions.  Since there is no uniformity among ASCs as to what items and services they include in their facility fee or charge, the Medicare definition of covered facility services is both inclusive and exclusive.  The regulations specify what are and are not facility services.  Facility services are items and services furnished in connection with listed covered procedures, which are covered if furnished in a hospital operating suite or hospital outpatient department in connection with such procedures.  These do not in clude physicians services, or medical and other health services for which payment may be made under other Medicare provisions (e.g., services of an independent laboratory located on the same site as the ASC, anesthetist professional services, non -implanta ble DME).   Examples of covered ASC facility services include:   Nursing Services, Services of Technical Personnel, and Other Related Services   These include all services in connection with covered procedures furnished by nurses and technical personnel who are employees of the ASC.  In addition to the nursing staff, this category includes orderlies, technical personnel, and others involved in pati ent care;   Use by the Patient of the ASCs Facilities   This category includes operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use by the patients relatives in connection with surgical services; and  Drugs, Biologicals, Surgical Dressings, Supplies, Splints, Casts, Appliances, and Equipment