Medicare considers payment for services that are medically necesssary, except as mandated by statute. For chiropractic services, this means the patient must have:
A significant health problem in the form of a neuromusculoskeletal condition necessitating treatment
Manual manipulation of the spine (by use of hands) to correct a subluxation as demonstrated by x-ray or physical exam
Must have a direct therapeutic relationship to the patient's condition
Provide a 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.
When required criteria are met, Medicare covers manual manipulation of the spine by chiropractors. No other diagnostic or therapeutic service furnished by a chiopractor or under the chiropractor's order is covered including but not limited to:
X-rays (spinal or other)
Evaluation & Management (E/M) services
Diagnostic studies
Physical and occupational therapy
Services such as office visits (evaluation and management services), diagnostic studies, physical therapy and other services rendered by chiropractic are not required to be submitted for coverage consideration by the Medicare program. The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a)(1)(A) of the Social Security Act. If a Medicare beneficiary believes a service may be covered or requests a formal Medicare determination for consideration by a supplemental plan, however, you must submit a claim.
To submit a claim for a non-covered service by a chiropractor, use HCPCS modifier GY to indicate that the service is statutorily excluded from coverage.
You may submit both covered and non-covered services on the same claim.
Although therapy services provided by a chiropractor are not covered, if the beneficiary asks you to file a claim for these services, they must be submitted with one of the following therapy modifiers:
HCPCS modifier GN - Services delivered under an outpatient speech-language pathology plan of care
HCPCS modifier GO - Services delivered under an outpatient occupational therapy plan of care
HCPCS modifier GP - Services delivered under an outpatient physical therapy plan of care
The documentation requirements apply for initial visits whether the subluxation is demonstrated by x-ray or by physical examination
The history the provider records in the patient record should include the following:
Chief complaint including the symptoms causing patient to seek treatment
Family history if relevant
Past medical history (general health, prior illness, injuries, hospitalizations, medications; surgical history)
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
Symptoms causing patient to seek treatment
Note: Symptoms must be related to the level of the subluxation that the doctor of chiropractic cites. A statement on a claim that there is “pain” is insufficient. Describe the location of the pain and whether the vertebra you listed can produce pain in that area.
Evaluation of musculoskeletal/nervous system through physical examination. If you demonstrate a subluxation you based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required and you need to document the criteria:
P - Pain/tenderness:
The perception of pain and tenderness is evaluated in terms of:
Location
Quality
Intensity
Most primary neuromusculoskeletal disorders manifest with a painful response. Pain and tenderness findings may be identified through one or more of the following:
Observation
Percussion
Palpation
Provocation, and so forth
Furthermore, pain intensity may be assessed using one or more of the following:
Visual analog scales
Algometers
Pain questionnaires, and so forth
A - Asymmetry/misalignment:
Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following:
Observation (such as posture and heat analysis),
Static palpation for misalignment of vertebral segments, and/or diagnostic imaging
R - Range of motion abnormality:
Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following:
Motion palpation
Observation
Stress diagnostic imaging
Range of motion, and/or other measurement(s)
T -Tissue tone, texture, and temperature abnormality:
Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following procedures:
Observation
Palpation
Use of instrumentation, and/or test of length and/or strength
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 bone named. The precise level of the subluxation must be specified by the doctor of chiropractic to substantiate a claim for manipulation of the spine.
The treatment plan should include:
Recommended level of care (duration and frequency of visists)
Specific treatment goals
Objective measures to evaluate treatment effectiveness
Date of initial treatment
Documentation requirements for subsequent visits
Documentation requirements for subsequent visits must include:
History:
Review of chief complaint
Changes since last visit
System review if relevant
Physical exam:
Exam of area of spine involved in diagnosis
Assessment of change in patient condition since last visit
Evaluation of treatment effectiveness
Documentation of treatment given on day of visit
The active treatment (AT modifier) was developed to clearly define the difference between active treatment and maintenance treatment. For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. The presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, Medicare may deny if appropriate after medical review.
Remember your documentation must support the use of the –AT modifier.
If codes 98940–98942 are billed without the AT modifier, the treatment will be considered maintenance therapy and will not be covered.
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