LCD Reference Article Billing and Coding Article

Billing and Coding: Chiropractor Services

A57914

Expand All | Collapse All
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.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57914
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Chiropractor Services
Article Type
Billing and Coding
Original Effective Date
01/01/2020
Revision Effective Date
01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

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

CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§30.5 and 240, 240.1, 240.1.1, 240.1.2, 240.1.3, 240.1.4. 240.1.5. Addresses Chiropractor's Services and Chiropractic Services - General, respectively.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §220. Addresses Chiropractic Services.

National policy limits the coverage of chiropractic services to the "hands on" manual manipulation of the spine for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943, CMT, extraspinal, one or more regions, is not a Medicare benefit.

Article Guidance

Article Text

As Noridian has recently retired the Chiropractic Services LCD, this article is offered to help guide in the billing, coding and documentation of chiropractic services, as supplementary to the provisions of the Medicare Benefit Policy Manual, Chapter 15, Section 30.5, and the Medicare Claims Processing Manual, Chapter 12, Section 220.

The following information must be documented in the medical record.

I. History:

• chief complaint including the symptoms present that caused the patient to seek chiropractic treatment.


II. Present Illness: This can include any of the following as appropriate:

• mechanism of trauma;
• quality and character of problem/symptoms;
• intensity of symptoms;
• frequency of symptoms occurring;
• location and radiation of symptoms;
• onset of symptoms;
• duration of symptoms;
• aggravating or relieving factors of symptoms;
• prior interventions, treatments, including medications;
• secondary complaints; and
• symptoms causing patient to seek treatment.

III. Family History: If pertinent

IV. Pertinent past health history which may include:

• general health statement
• prior illness(es)
• surgical history
• prior injuries or traumas
• past hospitalizations (as appropriate)
• medications

V. Physical examination: Evaluation of musculoskeletal/nervous system through physical examination to identify:

a. Pain/tenderness evaluated in terms of location, quality and intensity;
b. Asymmetry/misalignment identified on a sectional or segmental level;
c. Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
d. Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle and ligament.

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under physical examination are required, one of which must be asymmetry/misalignment or range of motion abnormality.

VI. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.

VII. Treatment Plan: The treatment plan should include the following:

• Therapeutic modalities to effect cure or relief (patient education and exercise training).
• The level of care that is recommended (the duration and frequency of visits).
• Specific goals that are to be achieved with treatment.
• Objective measures to evaluate treatment effectiveness.
• Date of initial treatment.

VIII. Subsequent Visits:

The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination for subsequent visits:

1. History:
Review of chief complaint;

Interval history, and system review if relevant.

2. Physical exam:
Exam of area of spine involved in diagnosis;
Assessment of change in patient condition since last visit;
Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

Medical Necessity of Treatment:

Failure to document that the chiropractic spinal manipulation is reasonable and necessary may result in denial of claim(s). This requirement may be fulfilled by indicating the Date of Service as a component of an ordered sequence of treatments in the treatment plan, i.e. #4 of ten planned adjustments".

Reasonable and necessary requirements may be additionally fulfilled by a comparative assessment of clinical treatment goals, compared to the assessment at the initial visit, and at the conclusion of a course of treatment.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.

 

 

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

N/A

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
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
999x Not Applicable
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
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2020 R1

Updated to indicate this article is not an LCD Reference Article.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
11/16/2023 01/01/2020 - N/A Currently in Effect You are here
01/10/2020 01/01/2020 - N/A Superseded View

Keywords

N/A