Sep 02 2009
Medicare Info 2009
Chiropractic Web Based Workshop Q&A for July 2009
The following questions and answers were prepared as a result of a web-based presentation by NAS Provider Education. In some cases, the questions have been edited for clarity and some of the original answers, given during the presentation, may have been expanded to provide further detail.
Q1. Is the use of code V57.9 (unspecified rehabilitation care) for maintenance care mandated or optional?
A1. Claims would be submitted using the appropriate diagnosis code for that visit, but if the provider knows this is maintenance care, add the optional additional diagnosis V57.9.
Q2. What criteria are used to determine whether a particular area of subluxation may have caused a patient’s complaint? Is there a reference guide or document that I can purchase or download?
A2. NAS has a Chiropractic Policy to assist providers. For the states of AZ, MT, ND, SD, UT and WY:
Navigate to https://www.noridianmedicare.com/macj3b/coverage/active.html on the NAS Web site.
Select your state from the drop down box listed “State” Enter “L24288″ in the box listed: “Search Terms:”
Click on the “Search CMS Site” button
Providers will be taken to the CMS Medicare Coverage Database (MCD) database - click on the bolded “L24288″ to open the “Chiropractic Services” NAS Local Coverage Determination (LCD)
Criteria listed under the documentation requirements
Providers may read online or download and print this Chiropractic Services LCD.
Q3. Please clarify the “Level of Care” that must be included on the treatment plan? Does that refer to the level of subluxation or maintenance care?
A3. CMS defines Level of Care as to the duration and frequency of visits that the provider is recommending for the acute treatment of the subluxation.
Q4. Are Chiropractors required to have the patient sign the back of the Advance Beneficiary Notice of Noncoverage (ABN) at each maintenance care visit or is that optional?
A4. If a patient continues to see the practice routinely, but medical necessity is not met and the services now became “maintenance”, patients must first sign the original ABN on the front with all pertinent information.
A4. If a patient continues to see the practice routinely, but medical necessity is not met and the services now became “maintenance”, patients must first sign the original ABN on the front with all pertinent information.
As long as the diagnoses and Current Procedural Terminology (CPT) remains the same, patients can sign the back (not initial) and date every visit (up to one year) or until there is a new injury, recurrence, etc. and returns to active care.
Append modifier GA (expect Medicare will deny an item or service as not reasonable and necessary and a signed ABN is on file) to the claim for transfer of liability to the patient. The AT modifier would not be used when the service is maintenance or supportive.
Q5. Please clarify whether the following items must be included into the chart notes for every single visit:
a) a complete description of the patient’s “chief complaint”;
b) a complete reiteration of the patient’s treatment plan;
c) narrative report that describes every step of the encounter.
A5. The clarifications are as follows:
a) The initial visit needs to be a complete review of chief complaint. For subsequent visits, the required components are the history with review of chief complaint, changes since last visit and systems review, if relevant.
b) Physical exam of spine area involved in diagnosis, with assessment of changes in patient’s condition since last treatment and evaluation of treatment effectiveness is required for initial visit. The treatment plan does not need to be repeated on subsequent visits; BUT there must be documentation of the treatment provided on that day.
c) Medicare regulations make it very clear that the documentation must meet the criteria for the service rendered. If the documentation does not establish the medical necessity for the services billed, then those services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Past experience has shown that most check sheet forms do not meet the requirements; generally because they are not fully utilized, not legible or in some cases are simply bad forms.
Q6. Some of our patients subscribe to Medicare Advantage plans that do not pay for out of network providers. We are out of their networks, the insurance companies have told us that they will not pay and do not want us to bill them. However, we are required to bill for all covered Medicare services. Our patients are aware that their insurance will not pay and they want to see our doctors anyway. We are a non-participating provider and our patients pay us at each visit. (Should we perhaps prepare an ABN, using the reason, “XXX [insurance carrier] will not pay for out-of-network services”?)
A6. Providers are encouraged to talk to the plan first, but if they need help from the CMS Regional Office, the best way is to send an e-mail to this address or call the phone number. Identify which plan, as there are specific plan managers in this division.
Contact information is as follows: Cathy Smerker, Associate Regional Administrator Phone: 206-615-3664
E-mail: ROSEA_DMHPO2@cms.hhs.gov
Q7. How would we bill a patient who has demonstrated medical necessity for cervical manipulation, but requests and receives a complete spinal manipulation? What about modifier 76?
A7. Bill the first line 98940AT (1-2 regions - Cervical, Acute Treatment modifier) for the manipulation meeting medical necessity. Bill the second line 98940GA (1-2 regions - Lumbar/Sacro), with a different diagnosis that addresses the additional spinal manipulation does not meet medical necessity. Obtain an Advance Beneficiary Notice of Noncoverage (ABN) and bill with GA modifier. Reflect in Item 19 or electronic equivalent “only cervical treatment covered, need denial for other areas. Modifier 76 is not used in Chiropractic medicine.
Q8. If Chiropractors only do modalities (i.e. ultrasound, massage) without a manipulation, do we still send a claim to Medicare?
A8. No, because these services are never covered or statutorily excluded. If the patients ask you to bill, so their secondary insurances may pay, providers are mandated to bill on their behalf using a modifier GY (item/service is non-covered (statutorily excluded) from the Medicare program). No ABN is needed and the claim is auto-denied by NAS.
Q9. Please clarify the new ABN. When can we use it and will consistent use of modifier GA trigger an audit?
A9. Chiropractors should use the ABN when the subluxation may be maintenance therapy. Consistent use of the GA modifier could raise a red flag. If you are unsure about maintenance therapy, append both modifiers AT and GA.
Q10. What if you do not have the referring physician’s National Provider Identifier (NPI) for Item 17 or electronic equivalent?
A10. Since the NPI 10-digit number is not releasing any HIPAA information and the Web site is secure, providers can call the referring physician’s office to ask for the NPI. Providers may also self-search for the NPI by signing on to the CMS Web site, under National Plan & Provider Enumeration System (NPPES), click into search and type the physician’s last name and city. The web address for the NPI national registry is: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
Q11. Does the x-ray date have to be mentioned in the documentation for subsequent visits?
A11 It is a good idea to have the x-ray date documented for subsequent visits in Item 19. The x-ray date is not required in subsequent notes.
Q12. Would a re-injury date replace the Initial Treatment Date (ITD) in Item 14?
A12. Yes, the exacerbation date of the existing condition.
Q13. For Range of Motion (ROM), is it necessary to use “goniometer” (instrument which measures an axis and range of motion) to measure? If not, what method is available? Is eyeball method/just measuring visibly acceptable?
Q13. No, it is not necessary to use a “goniometer” as Medicare will not pay for evaluating the ROM. The eyeball method is also not covered through Medicare. The method used to determine ROM is left to the individual provider. Medicare does not pay for any instrument used for this purpose.
Q14. Is there a list of standard Medicare abbreviations?
A14. A list of Medicare acronyms is located on the CMS Web site at: http://www.cms.hhs.gov/apps/acronyms/
Q15. If diagnosing subluxation using P.A.R.T. and/or x-ray, but pain is not one of the four required, why would diagnosing subluxation without pain, NOT be reimbursed by Medicare.
A15. There has to be a chief complaint. If there is no pain or discomfort, then there is no complaint. Medicare does not pay for maintenance or supportive care.
Q16. If services are not medically necessary, are we still required to use Medicare guidelines regarding cost to patient, or are we free to have more flexibility with finances?
A16. If services (98940 - 98942) are billed, which may or may not meet medical necessity, Chiropractors are still required to follow Medicare guidelines and fee schedules.
Q17. I am planning on moving my office and what is the best way to assure a smooth transition? Is there a checklist regarding change of address, etc.?
A17. Check the “Provider Interactive Enrollment Interview” on the Enrollment page of the NAS Web site.
Q15. If diagnosing subluxation using P.A.R.T. and/or x-ray, but pain is not one of the four required, why would diagnosing subluxation without pain, NOT be reimbursed by Medicare.
A15. There has to be a chief complaint. If there is no pain or discomfort, then there is no complaint. Medicare does not pay for maintenance or supportive care.
Q16. If services are not medically necessary, are we still required to use Medicare guidelines regarding cost to patient, or are we free to have more flexibility with finances?
A16. If services (98940 - 98942) are billed, which may or may not meet medical necessity, Chiropractors are still required to follow Medicare guidelines and fee schedules.
Q17. I am planning on moving my office and what is the best way to assure a smooth transition? Is there a checklist regarding change of address, etc.?
A17. Check the “Provider Interactive Enrollment Interview” on the Enrollment page of the NAS Web site.
Q18. Is Medicare considering expanding the CPT codes Chiropractors are allowed to use?
A18. No, currently there is no code expansion expected for Chiropractic services in the NAS states.
Q19. So a Chiropractor absolutely cannot see a patient who has Medicare coverage without billing Medicare, even if he/she tells the patient they do not participate in the Medicare program?
A19. Correct. Per the Mandatory Claim Submission Law of 1990, if a provider sees a Medicare patient for a covered service, they must bill Medicare for that patient.
Q20. Can Chiropractors bill Medicare for TENS units (E0730)?
A20. No, E0730 may not be billed to Medicare Part B. All Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS) items ordered by chiropractors are denied.
| Acronyms pertaining to Chiropractic medicine (Not all inclusive) | |
| ABN | Advance Beneficiary Notice |
| CMS | Centers for Medicare & Medicaid Services |
| CMT | Chiropractic Manipulation Treatment |
| COBC | Coordination of Benefits Contractor |
| ITD | Initial Treatment Date |
| MAC | Medicare Administrative Contractor |
| NPI | National Provider Identifier |
| PART | Pain, Asymmetry, Range of motion, Tissue tone changes |
| ROM | Range of Motion |
| SOAP | Subjective, Objective, Assessment, Plan |
| Indications and Limitations of Coverage and/or Medical Necessity | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 Act if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.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.
Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation. However, an x-ray may be used for this purpose if the chiropractor so chooses. The word “correction” may be used in lieu of “treatment.” Also, a number of different terms composed of the following words may be used to describe manual manipulation as defined above: - Spine or spinal adjustment by manual means; In any case in which the term(s) used to describe the service performed suggests that it may not have been treatment by means of manual manipulation, the carrier analyst refers the claim for professional review and interpretation. Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact. A subluxation may be demonstrated by an x-ray or by physical examination, as described below. 1. Demonstrated by X-Ray An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated. 2. Demonstrated by Physical Examination Evaluation of musculoskeletal/nervous system to identify: 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. The history recorded in the patient record should include the following: A - Documentation Requirements: Initial Visit The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination: 1. History as stated above. 2. Description of the present illness including: - Mechanism of trauma; These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo),bone (osseo or osteo), rib (costo or costal) and joint (arthro)and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined. 3. Evaluation of musculoskeletal/nervous system through physical examination. 4. 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. 5. Treatment Plan: The treatment plan should include the following: - Recommended level of care (duration and frequency of visits); 6. Date of the initial treatment. B - Documentation Requirements: Subsequent Visits The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination: 1. History 2. Physical exam 3. Documentation of treatment given on day of visit. The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services renderedmust 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 demonstrated by x-ray or physical exam as described above. Most spinal joint problems may be categorized as follows: 1. 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. 2. Chronic subluxation: A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as in 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. (Medicare Benefit Policy Manual 100-2, 15, 240.1.3) 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. 3. 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. 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 20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim. Maintenance therapy is not a covered benefit.
4. Exacerbations: An exacerbation is a temporary marked deterioration of the patient’s condition due to flare-up of the condition being treated. This must be documented on the claim form and must be documented in the patient’s clinical record, including the date of occurrence, nature of the onset or other pertinent factors that will support the reasonableness and necessity of treatments for this condition.
5. Recurrence: A recurrence is a return of symptoms of a previously treated condition that has been quiescent for 30 or more days. This may require the reinstitution of therapy. 6. Contraindications: 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. The following are relative contraindications to dynamic thrust: ? Articular hypermobility and circumstances where the stability of the joint is uncertain; 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; Location of Subluxation: The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified: Area of Spine - Names of Vertebrae - Number of Vertebrae - Short Form or Other Name Neck - Occiput (Occ, CO), Cervical (C1 thru C7), Atlas (C1), Axis (C2) - 7 Back - Dorsal (D1 thru D12) or Thoracic (T1 thru T12) or Costovertebral (R1 thru R12) or Costotransverse (R1 thru R12) - 12 Low Back - Lumbar (L1 thru L5) - 5 Pelvis - Iiii, r and l (I, Si) Sacral - Sacrum, Coccyx, S, SC In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment. There are two ways in which the level of the subluxation may be specified. Following are some common examples of acceptable descriptive terms for the nature of the abnormalities: Other terms may be used. If they are understood clearly to refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable. Treatment Parameters The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained. Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already “set” and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency. Some chiropractors have been identified as using an “intensive care” concept of treatment. Under this approach multiple daily visits (as many as four or five in a single day) are given in the office or clinic and so-called room or ward fees are charged since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare will be limited to not more than one treatment per day. Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review. |
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| CPT/HCPCS Codes back to top | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| ICD-9 Codes that Support Medical Necessity back to top | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Documentation Requirements
The following information must be documented in the patient’s clinical record on the initial visit:
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.
These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal), and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc.
Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such.
The subluxation must be causal, i.e., the symptoms must be related to the level of subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of the pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.
III. Family History: If pertinent
IV. 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.
The secondary diagnosis should come from:
Category I, II or III diagnosis (See ICD-9-CM Codes that Support Medical Necessity Section.)
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;
Changes since last visit;
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).
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 under Section 1862(a)(1) of the Social Security Act.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
1. Under “Physical Exam” in the Coding Guidelines Section, the draft LCD states: “The documentation of an exacerbation must be entered into the narrative field of an EMC claim or as an attachment with a CMS-1500 claim form.” We would like to go on the record relaying that we think this requirement will be an unnecessary hardship for practicing doctors. We are not aware of any other Medicare payers requiring this activity and think it will create a serious workload for both Noridian and provider.
NAS requires the documentation of an exacerbation on the CMS-1500 claim form to assist in the correct payment of claims on “first pass” and thus a benefit to the provider. This will continue to be required.
2. Under “Use of X-Rays” in the Coding Guidelines Section, the draft LCD states: “If an x-ray is used, a physician who is an MD or DO must order it (Medlearn Matters article SE0416). Manual 100-2 Chapter 15, Section 240.1.1.” X-rays utilized in the treatment of Medicare beneficiaries by doctors of chiropractic do not have to be ordered by doctors of medicine or osteopathy, as clearly stated by your own reference - Medicare Benefits Policy Manual, 100-2 Chapter 15, Section 240.1.1: “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.” [emphasis ACA]. Medlearn Matters SE0416 is confusing “demonstrating subluxation by using x-rays” and “reimbursement of x-rays”. We would ask Noridian to refer to the entire text of Medicare Benefits Policy Manual, 100-2 Chapter 15, Section 240.1.1 for the final chiropractic services LCD.
NAS understands the concern raised here, but CMS has incorporated language in MLM SE0416 that further clarifies sections of the Manual. NAS will continue to reference both the Manual and MLM as references for providers to access.
3. Under “VII Treatment Plan” in the Documentation Requirements Section, a treatment plan is described as including:
- 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.
- The objective measures that will be used to evaluate the effectiveness of treatment.
- Date of initial treatment.
We would like to point out that national policy, as outlined in the Medicare Benefit Policy Manual 100-2, Chapter 15, 240.1.2, 2, A, 5 consists of only three of these bulleted points: level/duration, specific goals, and objective measures. The date of initial treatment is a requirement for the initial visit, but not specifically for the treatment plan (which. of course, is part of the initial visit). To avoid confusion, we would recommend that this be clarified in the final LCD.
Medicare notes in the Medicare Benefit Policy Manual 100-2, Chapter 15, 240.1.2, 2, A, 5 that “The treatment plan should include the following:” This requirement is not restrictive, and NAS has found that the addition of the “Therapeutic Modalities” and the “Date of Initial Treatment” to the Treatment Plan aid in validation during adjudication of these claims. NAS will clarify the language from modalities to procedures in these requirements to help avoid confusion over listing non-covered services. NAS will also use the CMS phrase “Objective measures to evaluate treatment effectiveness”.
4. As a long term practicing physician I would like to comment regarding the content of the current LCD policies as they pertain to Chiropractic Services, and specifically to the definition of “Maintenance” care. The policy currently in place appears to be in direct contradiction to the industry standard for “supportive” versus “maintenance” care, as established by the universal healthcare community.
11/09/2008 - The description for CPT/HCPCS code 98940 was changed in group 1
11/09/2008 - The description for CPT/HCPCS code 98941 was changed in group 1
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