Documentation and billing of chiropractic treatment

by Valerie A. Rinkle, MPA

CMS released a series of special edition articles applicable to chiropractic services on March 16.  These articles address questions raised during a special Open Door Forum (ODF) call on September 24, 2015, about the high percentage of documentation errors discovered by CERT audits in 2014. 

Medicare has a very limited coverage benefit for chiropractic services. The Medicare Benefit Policy Manual, Chapter 15 outlines coverage in section 30.5, Chiropractor’s Services.  The benefit applies only to a primary diagnosis of acute or chronic subluxation of the spine undergoing active treatment. Maintenance treatment is not covered. Furthermore, the manipulative services rendered by the chiropractor must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. This standard of medical necessity must be evident in the documentation.

Section 240.1.3 of the Medicare Benefit Policy Manual discusses the medical necessity of treatment and further defines the two covered primary diagnostic conditions. Acute subluxation occurs when the patient is being treated for a new injury. Chronic subluxation exists when the subluxation is not expected to significantly improve or be resolved with further treatment; rather, the continued therapy should be expected to result in functional improvement. Once the clinical status plateaus and remains stable, without expectation of additional objective clinical improvement, further manipulative treatment is considered maintenance therapy and is not covered. Initially, subluxation had to be verified by x-ray. As of January 1, 2000, an x-ray was no longer required. As an alternative, subluxation could be verified with an initial physician examination by the chiropractor. If used as the basis to verify subluxation, the x-ray must have been taken reasonably close to (within 12 months prior or three months following) the beginning of treatment unless the patient is being treated for a chronic condition such as scoliosis.

As of October 2, 2004, every chiropractic claim, to be covered and payable by Medicare, required an AT modifier to be affixed to one of the three CPT® codes recognized:

• 98940 (chiropractic manipulative treatment; spinal, one to two regions)
  
  • 98941 (three to four regions), or
  • 98942 (five regions)

The AT modifier is an attestation of sorts. An AT modifier means the chiropractic manipulation is expected to result in an improvement in, or arrest of progression of, an acute subluxation condition. For chronic conditions, the chiropractic manipulation is expected to result in functional improvement. MACs are not to pay the above CPT codes if they do not have the AT modifier attached but merely attaching the AT modifier, in and of itself, does not indicate the service is medically necessary. Therefore, all the documentation requirements and the clinical picture must substantiate the attestation of active treatment of an acute condition or improved function for a chronic condition.

In SE1601, CMS provides detailed explanations of documentation requirements along the lines of the 1995 and 1997 Evaluation and Management (E/M) Documentation Guidelines. For the initial visit, CMS requires proof of the spinal subluxation either from an x-ray or physician examination. Note that the x-ray for subluxation of the spine is the only diagnostic service that can be ordered by a chiropractor. All other diagnostic services require the order of a treating physician or non-physician practitioner (e.g., NP, PA, CNS). 

To view the complete article that appeared on Medicare Compliance Watch, click here.