The American Chiropractic Association estimates that chiropractors see about 35 million people in the United States annually. Chiropractors typically treat musculoskeletal disorders such as back and neck pain, other conditions affecting the joints, ligaments and muscles, and headaches. Many practices rely on chiropractic billing services to get optimal reimbursement for spinal manipulation procedures and other treatments.
Chiropractic is an alternative for surgical treatment and pain medications. With many people 65 and older turning to chiropractic care, one question that comes up is: does Medicare cover chiropractic services? Let’s take a look at what chiropractic services Medicare covers and the codes to report these services.
Conditions for Medicare Coverage of Chiropractic Services
Medicare.gov states: “Medicare Part B (Medical Insurance) covers manual manipulation of the spine provided by a chiropractor or other qualified provider if medically necessary to correct a subluxation. Medicare doesn’t cover other services or tests a chiropractor orders, including X-rays, massage therapy, and acupuncture.”
This indicates that Medicare coverage of chiropractic services is available only for treatment by means of manual manipulation (using hands) of the spine to correct a subluxation. United Healthcare Medicare Advantage lists the conditions for Medicare coverage for chiropractic care as follows:
- The patient must require treatment by means of manual manipulation of the spine to correct a subluxation.
- The manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
- Manual devices (those that are handheld with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine, but no additional payment is available for use of the device
- The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for the treatments. The chiropractor must specify the precise level(s) of the subluxation(s) to support a claim for manipulation of each spinal region(s).
- The need for an extensive, prolonged course of treatment should be appropriate to the reported procedure code(s) and must be documented clearly in the medical record.
- An x-ray or any diagnostic test taken in order to determine or demonstrate the existence of a subluxation of the spine is covered if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.
- Medicare coverage for treatment by means of manual manipulation of the spine to correct a subluxation will be provided only if such treatment is legal in the State where performed.
Use of the AT Modifier
The (AT) modifier is intended to distinguish between active treatment and maintenance treatment. Medicare pays for active/corrective treatment for acute or chronic subluxation and not for maintenance therapy.
- The chiropractor must place an Active Treatment (AT) modifier on a claim submitted to Medicare when providing active/corrective treatment to treat acute or chronic subluxation.
- Modifier AT must only be used when the chiropractic manipulation is “reasonable and necessary” as defined by national policy and the LCDs. Modifier AT must not be used when maintenance therapy has been performed.
UnitedHealthcare further states that the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary and that they may deny if appropriate after medical review.
ICD-10 Codes for Medicare Covered Chiropractic Services
Chiropractic service may be covered when CPT codes 98940, 98941, or 98942 are billed with one of the following primary diagnosis codes and with modifier AT:
M99.00 Segmental and somatic dysfunction of head region
M99.01 …cervical region
M99.02 … thoracic region
M99.03 …lumbar region
M99.04 …sacral region
M99.05 …pelvic region M99.10 Subluxation complex (vertebral) of head region
M99.11 …cervical region
M99.12 … thoracic region
M99.13 … lumbar region
M99.14 … sacral region
M99.15 … pelvic region
M99.20 Subluxation stenosis of neural canal of head region
M99.21 … cervical region
M99.22 … thoracic region
M99.23 … lumbar region
S13.100A Subluxation of unspecified cervical vertebrae, initial encounter
S13.110A Subluxation of C0/C1 cervical vertebrae, initial encounter
S13.120A Subluxation of C1/C2 cervical vertebrae, initial encounter
S13.130A Subluxation of C2/C3 cervical vertebrae, initial encounter
S13.140A Subluxation of C3/C4 cervical vertebrae, initial encounter
S13.150A Subluxation of C4/C5 cervical vertebrae, initial encounter
S13.160A Subluxation of C5/C6 cervical vertebrae, initial encounter
S13.170A Subluxation of C6/C7 cervical vertebrae, initial encounter
S13.180A Subluxation of C7/T1 cervical vertebrae, initial encounter
S23.100A Subluxation of unspecified thoracic vertebra, initial encounter
S23.110A Subluxation of T1/T2 thoracic vertebra, initial encounter
S23.120A Subluxation of T2/T3 thoracic vertebra, initial encounter
S23.122A Subluxation of T3/T4 thoracic vertebra, initial encounter
S23.130A Subluxation of T4/T5 thoracic vertebra, initial encounter
S23.132A Subluxation of T5/T6 thoracic vertebra, initial encounter
S23.140A Subluxation of T6/T7 thoracic vertebra, initial encounter
S23.142A Subluxation of T7/T8 thoracic vertebra, initial encounter
S23.150A Subluxation of T8/T9 thoracic vertebra, initial encounter
S23.152A Subluxation of T9/T10 thoracic vertebra, initial encounter
S23.160A Subluxation of T10/T11 thoracic vertebra, initial encounter
S23.162A Subluxation of T11/T12 thoracic vertebra, initial encounter
S23.170A Subluxation of T12/L1 thoracic vertebra, initial encounter
S33.100A Subluxation of unspecified lumbar vertebra, initial encounter
S33.110A Subluxation of L1/L2 lumbar vertebra, initial encounter
S33.120A Subluxation of L2/L3 lumbar vertebra, initial encounter
S33.130A Subluxation of L3/L4 lumbar vertebra, initial encounter
S33.140A Subluxation of L4/L5 lumbar vertebra, initial encounter
CPT codes 98940, 98941, or 98942 billed with specific primary diagnosis codes without modifier AT may be covered by Medicare if there is a supplemental chiropractic benefit.
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