Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques. Medicare covers limited chiropractic services when performed by a chiropractor who is licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which the services are furnished (CMS Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 70.6). A chiropractor must also meet uniform minimum standards as set forth in the CMS Internet-Only Manual (IOM) Publication 100-1, Chapter 5, Section 70.6. This article restates language directly from the CMS Internet-Only manuals and if necessary provides clarification to educate providers on specified Medicare requirements for the diagnosis, treatment, documentation and billing of chiropractic services.
Chiropractic Services – Active Treatment:
The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and 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. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3).
Most spinal joint problems fall into the following categories:
Acute subluxation - A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.
Chronic subluxation - A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3).
An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is causing significant interference with activities of daily living due to an acute flare-up of the previously treated condition. The patient’s clinical record must specify the date of occurrence, nature of the onset, or other pertinent factors that would support the medical necessity of treatment. As with an acute injury, treatment should result in improvement or arrest of the deterioration within a reasonable period of time.
A. Maintenance Therapy
Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A)
Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B)
The following are relative contraindications to Dynamic thrust:
Articular hyper mobility and circumstances where the stability of the joint is uncertain;
Severe demineralization of bone;
Benign bone tumors (spine);
Bleeding disorders and anticoagulant therapy;
and Radiculopathy with progressive neurological signs.(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B).
Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:
Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
An unstable os odontoideum;
Malignancies that involve the vertebral column;
Infection of bones or joints of the vertebral column;
Signs and symptoms of myelopathy or cauda equina syndrome;
For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and A significant major artery aneurysm near the proposed manipulation.(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B).
The term “physician” under Part B includes a chiropractor who meets the specified qualifying requirements set forth in §30.5 but only for treatment by means of manual manipulation of the spine to correct a subluxation. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240)
Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. All other services furnished or ordered by chiropractors are not covered. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30.5)
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 Act if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.1)
The mere statement or diagnosis of "pain" is not sufficient to support medical necessity for the treatments. 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). There are five spinal regions addressed: cervical region (atlanto-occipital joint), thoracic region (costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region (ref. CPT® Professional Edition 2017 p. 672).
Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943). The five extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen (CPT Assistant Nov 98:38).
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. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3). Modifier AT must only be used when the chiropractic manipulation is “reasonable and necessary” as defined by national policy. 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) and medical necessity must be documented clearly in the medical record.
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines:
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Specific coding guidelines for this policy:
The precise level of the subluxation must be listed.
The date of the initial treatment or date of exacerbation of the existing condition must be entered in Item 14 of the CMS-1500 form or the electronic equivalent.
If using an x-ray as documentation of the subluxation, the date of the x-ray (or existing MRI or CT scan) must be entered in Item 19 of the CMS-1500 form or the electronic equivalent.
If an authorized ordering practitioner orders the x-ray, then he/she should enter his/her name in Item 17 of the CMS-1500 form and his/her own NPI number in Item 17a of the CMS-1500 form, or the electronic equivalent, as the ordering physician.
The HCPCS modifier AT (acute treatment) must be appended to the chiropractic manipulation code to indicate the manipulation was for medically necessary and reasonable treatment of an acute subluxation or chronic subluxation as defined in national policy and the LCD.
The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied. Chiropractors who give or receive from beneficiaries an ABN shall follow the instructions in Pub. 100-04, Medicare Claims Processing Manual, chapter 23, section 22.214.171.124 and include a GA (or in rare instances a GZ) modifier on the claim. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: Section 240.1.3)
For claims submitted to the Part B MAC: All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.