LCD Reference Article Billing and Coding Article

Billing and Coding: Chiropractic Services

A56616

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56616
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Chiropractic Services
Article Type
Billing and Coding
Original Effective Date
06/13/2019
Revision Effective Date
10/10/2019
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

42 CFR §410.21 describes limitations on services of a chiropractor.

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, §70.6 Chiropractors.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §30.5 Physician Services-Chiropractor’s Services.

 

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Chiropractic Services L37387.

Limitations:

Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, 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.

No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s 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 Social Security Act if ordered, taken and interpreted by a physician who is a doctor of medicine or osteopathy.

The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s).

Medicare does not cover chiropractic treatments to extraspinal regions.

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, contractors may deny if appropriate after medical review. Modifier AT must only be used when the chiropractic manipulation is “reasonable and necessary” as defined by national policy and the Chiropractic Services L37387 LCD. Modifier AT must not be used when maintenance therapy has been performed. The need for a prolonged course of treatment should be appropriate to the reported procedure code(s).

The precise level of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. A statement on a claim that there is “pain” is insufficient.

Only 1 chiropractic manipulation service for a beneficiary can be reimbursed per day.

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
98940 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 1-2 REGIONS
98941 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 3-4 REGIONS
98942 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 5 REGIONS
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CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

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Group 1 Codes
Code Description
AT ACUTE TREATMENT (THIS MODIFIER SHOULD BE USED WHEN REPORTING SERVICE 98940, 98941, 98942)
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ICD-10-CM Codes that Support Medical Necessity

Group 1

(5 Codes)
Group 1 Paragraph

The use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the Chiropractic Services L37387 LCD.

Group 1 Codes
Code Description
M99.01 Segmental and somatic dysfunction of cervical region
M99.02 Segmental and somatic dysfunction of thoracic region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.05 Segmental and somatic dysfunction of pelvic region
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/10/2019 R2

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Chiropractic Services L37387 LCD and placed in this article. Under CPT/HCPCS Modifiers added modifier AT.

06/13/2019 R1

All coding located in the Coding Information section has been removed from the related Chiropractic Services L37387 LCD and added to this article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L37387 - Chiropractic Services
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
10/02/2019 10/10/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Chiropractic