Chiropractic Medical Billing for Medicare Claims-Key Points to Note

by | Published on Apr 12, 2017 | Medical Billing

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Today, an increasingly large number of chiropractors are choosing to outsource their billing and coding tasks. Experienced medical billing companies provide chiropractic billing services to ensure compliance with payer mandates, ensure appropriate claim reimbursement.

When it comes to Medicare payments, things can get quite complex as Medicare has several requirements that chiropractors must comply with. In fact, according to a 2016 Department of Health and Human Services Office of Inspector General (OIG) Report, up to 82 percent of all Medicare Part B payments for chiropractic services in 2013 were improper because they were for medically unnecessary services. By outsourcing medical billing to a reliable service provider, chiropractors can rest assured that their practice meets Medicare requirements for documentation, coding and billing for proper payment, avoiding denials and paybacks. There are changes to Medicare billing for chiropractic services in 2017, which makes such support even more critical.

Medicare Coverage of Chiropractic Services

  • Medicare Part B covers the chiropractic services provided by a qualified chiropractor who is licensed and authorized by the State or jurisdiction in which the services are provided.
  • Medicare coverage of chiropractic services is limited to manual manipulation of the spine (using the hands or handheld devices) to correct a spinal subluxation. There is no separate payment for the device.
  • Medicare does not cover extremity (hip, knee, foot, wrist, elbow, etc) adjustments, examinations, X-rays, therapeutic exercises, deep tissue work, kinesiotaping, ultrasound or electronic muscle stimulation.
  • Medicare pays for acute care or active treatment.
  • Medicare does not cover chiropractic wellness care, maintenance care, or preventative care.
  • When no longer in active care according to Medicare guidelines, the patient will be moved to maintenance care. In this case, payment for maintenance services becomes the patient’s responsibility.
  • For provision of active/corrective treatment for subluxation, claims must be submitted with an AT (Acute Treatment) modifier; inclusion of the AT modifier is not considered as always indicating that the service provided was reasonable and necessary.

Documentation essentials for Medicare payments

  • The mechanism of trauma must be clearly documented. If the patient cannot correlate the mechanism of pain to any specific activity, this must be mentioned in the initial documentation.
  • In addition to history and description of illness, the physical exam evaluation and management (E/M) documentation should include vitals, spinal evaluation, neurological and orthopedic evaluation.
  • Services provided during the initial and subsequent visits must be documented as to meet the Benefit Manual and the applicable Local Coverage Determinations (LCDs) for chiropractic services.
  • To affirm that all documentation required by Medicare is being maintained on file, the chiropractor has to affix the date of the initial treatment on the claim.
  • The primary diagnosis must be subluxation, including the level of subluxation. ICD-10 code M99.0 is appropriate to report segmental and somatic dysfunction.
  • The precise level of subluxation should be specified in order to validate a claim for manipulation of the spine.
  • While subluxation must be the primary diagnosis, incorporating the secondary diagnosis is important as it is most specific reason for the encounter.
  • If the chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate spinal subluxation, the x-ray can be used for documentation. However, the chiropractor will not receive payment for these services or for any other diagnostic or therapeutic service.
  • The documentation of the treatment plan should include a recommended level of care or duration and frequency of visits. For duration of care, Medicare expects episode of care details, that is, a beginning and an end of care. Though projecting the actual duration of care is difficult, this must be done as best as possible.

Also, treatment goals should be patient specific functional goals. Functional outcome assessments should be used to quantify the necessity and progress of the treatment plan. CMS has made the use of outcome measures mandatory from 2015 under PQRS reporting.

Based on the number of spinal regions treated, chiropractors may bill Medicare for chiropractic manipulative treatment using one of three Current Procedural Terminology (CPT)11 codes:

  •  98940 – for treatment of one or two regions
  • 98941 – for treatment of three or four regions
  • 98942 – for treatment of all five regions

All Medicare claim submitted are audited/reviewed to protect Medicare trust funds and also to identify billing errors. According to the Office of Inspector General Report, the Center for Medicare and Medicaid Services (CMS) announced that provisions for oversight include requiring preauthorization of services provided by chiropractors with aberrant billing or high rates of denials. The best way to understand Medicare coverage, reimbursement, and billing requirements and avoid audits through proper coding, documentation and claim processing practices is to partner with an experienced chiropractic medical billing company.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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