CMS’ Guidelines on
Chiropractic Medical Billing – A Review
Chiropractic billing services offered by reliable outsourcing companies ensure that the documentation is done in keeping with standard medical billing instructions and guidelines.
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Filling out medical claims forms, documenting claims diagnosis and procedure codes, and sending them to insurance companies for payment are all part of the normal medical billing process for any medical specialty. But what makes the chiropractic specialty different? Several reports indicate that CMS continues to deny many chiropractic claims as they do not meet
Medicare
requirements.
The
most
common
reason
for
denial
is insufficient
documentation to support the billed services. Chiropractic billing services can help providers avoid denied claims and overpayment recovery with their thorough understanding of Medicare requirements, especially documentation and medical necessity.
Follow CMS’ Instructions Correct claim payment depends largely on providers complying with Medicare requirements for coverage, coding, and documentation of services. Compared to other specialties, chiropractic includes certain restrictions such as: ❖ Insurance coverage limitations - Insurance coverage of chiropractic treatments is specifically limited to treatment by means of manual manipulation of the spine to correct a subluxation. No other treatments performed by the chiropractor will be reimbursed by Medicare. Manual manipulation can also be referred to as spinal adjustment by manual means, spinal manipulation, adjusted manually and vertebral manipulation/adjustment. Though manual devices can be used by chiropractors in performing manual manipulation of the spine, no additional payment is available for the use of the device, nor does Medicare recognize an extra charge for the device itself. If the chiropractor uses an x-ray or other diagnostic service to find and diagnose the subluxation, they can be used for further documentation. However, Medicare won't reimburse for the use of an x-ray machine or for the extended examination. ❖ Exact documentation of subluxation – It is critical for chiropractors to document the exact location of the subluxation in the patient's medical chart. These locations range from the occipital vertebrae in the neck to the sacral vertebrae and coccyx. The condition can also be specified by referring to the exact bones that are out of place, or by referring to a certain area or set of vertebrae that are out of place. Other terms to indicate subluxation are – Misaligned, Off-center, Malpositioned, Rotated and Incomplete dislocation.
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Phone: 1-800-670-2809
Subluxation based on physical examination can be demonstrated by pain or tenderness in a specific location, asymmetry/misalignment of a sectional of segmental level, range of motion abnormality and tissue or tone changes in soft tissue. ❖ Use of AT modifier - The Active Treatment (AT) modifier can clearly define the difference between active treatment and maintenance treatment. Medicare pays only for active/corrective treatment to correct acute or chronic subluxation. A chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. Medicare does not pay for maintenance therapy. 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. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. AT modifiers assist providers in correctly documenting claims for chiropractic services provided to Medicare beneficiaries. The modifier is required under Medicare billing to receive reimbursement for the procedure codes – •
98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions
•
98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions
•
98942 Chiropractic manipulative treatment (CMT); spinal, five regions
❖ Advance Beneficiary Notice of Non-coverage (ABN) – Chiropractors can provide the Advance Beneficiary Notice of Non-coverage (ABN) to the beneficiary, if Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. If the beneficiary decides to receive the service further, a claim must be submitted to Medicare even though claim will be denied and the beneficiary will have to pay. It is important that the patient's medical record should support the services submitted. Claims should include a primary diagnosis of subluxation and a secondary diagnosis that reflects the patient's neuro-musculoskeletal condition. Also, make sure to use the appropriate CPT and ICD-10 codes that best describe the treatment provided.
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Phone: 1-800-670-2809