CPT CODES – 98940, 98941, 98943, 98942 – Chiropractic billing with AT modifer

procedure code and description

98940–  Chiropractic manipulative treatment (CMT); spinal, one or two regions. Documentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT). – average fee payment-$20 – $30

98941- Chiropractic manipulative treatment (CMT); spinal, three or four regions.

Documentation must support that manipulative treatment occurred in three or four regions of the spine (region as defined by CPT) and one of the following: validated diagnoses for three or four spinal regions or validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings. –  average fee payment- $40 – $50

98942 Chiropractic manipulative treatment (CMT); spinal, five regions. Documentation must support that manipulative treatment occurred in five regions of the spine (region as defined by CPT) and one of the following: validated diagnoses for five spinal regions or validated diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings validated diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings.

98943 Chiro, manipulation, extraspinal, one or more regions

Key Billing Requirements

In addition to other billing requirements explained in Medicare’s Manuals, it is important that you include the following information on the claim:

• The primary diagnosis of subluxation;

• The initial visit or the date of exacerbation of the existing condition;

• The appropriate Current Procedural Terminology (CPT) code that best describes the service:

o 98940: Chiropractic Manipulative Treatment (CMT); spinal, one or two regions;

o 98941: Spinal, three to four regions;

o 98942: Spinal, five regions.


NOTE: 98943: CMT, extraspinal, one or more regions, is not covered by Medicare.

• The appropriate modifier that describes the services:

o AT modifier* used on a claim when providing active/corrective treatment to treat acute or chronic subluxation;

o GA modifier used to indicate that you expect Medicare to deny a service (e.g., maintenance services) as not reasonable and necessary and that you have on file an Advance Beneficiary Notice (ABN) signed by the beneficiary; or

o GZ modifier used to indicate that you expect that Medicare will deny an item or service as not reasonable and necessary and that you have not had an ABN signed by the beneficiary, as appropriate.

NOTE: You must use the Acute Treatment modifier “AT” to identify services that are active/corrective treatment of acute or chronic subluxation and must document services in accordance with the Centers for Medicare & Medicaid Services’ (CMS) “Medicare Benefit Policy Manual”, Chapter 15, Section 240, when submitting claims.

Are we required to submit a claim to Palmetto GBA for maintenance therapy?

Answer:
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.

Medicare recommends that you consider providing the Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary. The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The beneficiary can then make a reasonable and informed decision about receiving and paying for the service.

On the ABN, if the beneficiary selects option one, she/he is agreeing to pay out of pocket for the service in question and requests that the chiropractor file a claim for that service with Medicare. With option one selected, the beneficiary retains appeals rights if he/she disagrees with Medicare’s claim decision. The chiropractor is permitted to ask for payment from the beneficiary.

If a beneficiary selects option two when he/she agrees to pay out of pocket for the service in question and does not want a claim sent to Medicare. In accordance with the ABN, the provider would not file a claim, and the beneficiary would not have appeal rights since no claim is being submitted. (Please note that the patient can change his/her mind at a future time and request the claim be submitted.)

If a beneficiary selects option three he/she chooses not to receive and pay for the service. No service is rendered, and no claim is filed. Since no claim is filed, the patient cannot appeal to Medicare for a payment decision.

Can a chiropractor use a manual device to assist with manipulation?

Answer:
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.

Coverage Indications, Limitations, 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;
– Spine or spinal manipulation;
– Manual adjustment; and
– Vertebral manipulation or adjustment.

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:
– Pain/tenderness evaluated in terms of location, quality, and intensity;
– Asymmetry/misalignment identified on a sectional or segmental level;
– 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
– 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.

The history recorded in the patient record should include the following:
– Symptoms causing patient to seek treatment;
– Family history if relevant;
– Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
– Mechanism of trauma;
– Quality and character of symptoms/problem;
– Onset, duration, intensity, frequency, location and radiation of symptoms;
– Aggravating or relieving factors; and
– Prior interventions, treatments, medications, secondary complaints.

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;
– Quality and character of symptoms/problem;
– Onset, duration, intensity, frequency, location, and radiation of symptoms;
– Aggravating or relieving factors;
– Prior interventions, treatments, 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 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);
– Specific treatment goals; and
– Objective measures to evaluate treatment effectiveness.

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
– 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.

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;
?Severe demineralization of bone;
? Benign bone tumors (spine);
? Bleeding disorders and anticoagulant therapy; and
? Radiculopathy with progressive neurological signs.

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 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.

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.
– The exact bones may be listed, for example: C5, C6, etc.
– The area may suffice if it implies only certain bones such as: Occipito-atlantal (occiput and C1 (atlas)), lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).

Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:
– Off-centered
– Misalignment
– Malpositioning
– Spacing – abnormal, altered, decreased, increased
– Incomplete dislocation
– Rotation
– Listhesis – antero, postero, retro, lateral, spondylo
– Motion – limited, lost, restricted, flexion, extension, hyper mobility, hypomotility, aberrant

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.

Chiropractic Manipulative Treatment Denials




Denial Reason, Reason/Remark Code(s)

CO-18 – Duplicate Service(s): Same service submitted for the same patient, same date of service by same doctor will be denied as a duplicate

CO-151 – Information provided does not support this many/frequency of services. Same service submitted for the same patient, same date of service by the same provider will be denied.

CPT codes: 98940, 98941, 98942

Resolution/Resources

First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA eServices tool or by calling the Palmetto GBA Interactive Voice Response (IVR) unit.

Please note:

Only one chiropractic manipulative treatment will be allowed per day

Billing Information

Procedure codes 97260 and 97261 have been deleted in the Current Procedural Terminology manual (Procedure ). Chiropractors are to bill for services using the appropriate, current Procedure  code (98940 or 98941) for the service provided. HCPCS modifier “AT” (Acute Treatment) may be appended.

Claims for chiropractic services pend to Medical Review and must be submitted hardcopy. The claim is to be accompanied by a written, dated, and signed referral statement from EPSDT medical screening provider or PCP and documentation substantiating the medical necessity of the services. The documentation should include, but is not limited to:

• Diagnosis and chief complaint

• Relevant history

• Subjective and objective diagnostic examination findings

• Acuity and severity of the patient’s condition

• Results of X-ray, lab and other diagnostic tests

• Number of treatment sessions necessary to correct or alleviate the patient’s symptoms or problem

• The level of care (relief, therapeutic, rehabilitative, supportive) planned

• Procedures performed and results

• Response to therapy

• Progress notes and patient disposition


Beneficiary Responsibility

For Medicare covered services, the beneficiary pays the Part B deductible and then 20 percent of the Medicare-approved amount. The beneficiary also pays all costs for any services or tests you order. If you provide an ABN, you must submit a claim to Medicare, even though you expect the beneficiary to pay and you expect Medicare to deny the claim.

CPT describes chiropractic manipulative treatment (CMT) as, “…a form of manual treatment to influence joint and neurophysiologic function. This treatment may be accomplished using a variety of techniques.” A series of three CMT codes (98940, 98941, 98942) has been developed to describe the number of spinal regions receiving manipulation. A single extraspinal CMT code (98943) is used by chiropractors to describe manipulative services directed at the head, extremities, rib cage, and abdomen.

Correct coding emphasizes that procedures should be reported with the CPT codes that most comprehensively describe the services performed e.g., 98941 is a more comprehensive code than 98940. There are procedural codes that are not to be reported together because they are mutually exclusive to each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session. An example of mutually exclusive codes germane to this policy is 97140 – Manual therapy techniques (without the -59 modifier) vs. 98940, 98941, 98942, or 98943 – Chiropractic manipulative treatment.

Chiropractic Manipulative Treatment (CMT)


CPT CPT Description Reimbursement Policy

98940 CMT; spinal, one to two regions

98941 CMT; spinal, three to four regions

98942 CMT; spinal, five regions

Indications


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.

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.

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.


B. 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 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.
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.

Limitations

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.

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.

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.

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). The need for an extensive, prolonged course of treatment should be appropriate to the reported procedure code(s) and must be documented clearly in the medical record.

The five extraspinal regions referred to are: head (including, temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib care (excluding costotransverse and costovertebral joints) and abdomen . Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage and abdomen.

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 LCD. Modifier AT must not be used when maintenance therapy has been performed.

Billing and Coding Guidelines.

Payment is allowed for one clinically indicated and  medically necessary spinal manipulation code per date of service. Reimbursement of specific CMT codes is subject to the subscriber certificate.




Extraspinal Manipulation + Spinal Manipulation
Modifier -51 (Multiple Procedures) is not required to be appended to the extraspinal CMT procedural code (98943), when billed on
the same date of service as a spinal CMT code (98940-98942).

It is not appropriate to use modifier 52 with any of the CMT codes or timed therapy codes.

• Modifier 52 identifies a reduced service but should not be used to identify another procedure if there is a specific CPT® code for the reduced service.

• Codes for spinal manipulations (98940 – 98942) are specific to the number of regions treated. If only two regions are treated, 98940 should be used instead of 98941–52

Claims submitted for CPT code 98940, 98941, or 98942 with the demonstration code “demo 45” shall be rejected.

Effective immediately, carrier(s) shall educate chiropractors in the four demonstration sites that current Medicare coverage policies for codes 98940, 98941, and 98942 remain in effect. Chiropractors will continue to be paid according to the current fee schedule rate for these three codes.

Chiropractors must apply demonstration code 45 to all demonstration claims. On the 837 professional transaction,  chiropractors should report the demonstration number “45” in Loop 2300 REF02 (REF01=P4). If chiropractors are using the CMS-1500 claim form, the demonstration number should be inserted in Box 19 (reserved for local use) along with the word “demo” before the number 45

You will be required to submit claims for demonstration services separately from claims for CPT codes 98940, 98941, and 98942. For example, if you submit claims for CPT codes 98940 through 98942 with demonstration services and the demonstration code 45, the non-demonstration services will be rejected and you will have to resubmit the non-demonstration services. The demonstration services will be paid

If you submit a claim for CPT codes 98940 through 98942 with demonstration services and the demonstration code 45 is not included, the demonstration services will be rejected and you should resubmit them as a separate claim. The non-demonstration services will be paid in this instance.

Chiropractors should also be aware that they will be subject to the current version of the National Correct Coding Edits (CCI) which can be found at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.
Other points of interest to you are as follows:

• CPT codes currently exist for the services that you will provide under this demonstration (See Tables 5 and 6). Your Medicare carrier will develop edits to recognize chiropractors in these four geographic areas and allow you to be reimbursed for your authorized medical, radiology, clinical lab, and therapy services. Information regarding fees for demonstration services (except 98943, which is found in Table 1) can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/index.html on the CMS website.

• Current Medicare coverage for chiropractic services (codes 98940, 98941, and 98942) remains unchanged. The fee schedule for these three codes will continue to apply.

Medicare Coding and Billing

* The procedure codes that chiropractors use to bill covered procedures to Medicare are: o 98940 o 98941 o 98942

GA Modifier

* The GA code signifies the “Waiver of Liability Statement Issued as Required by Payer Policy.”

* The GA modifier does not signify that the care is maintenance.

* If you place the GA modifier on a code you must have a signed ABN form in the file.

* It is appropriate to report the GA modifier when the beneficiary refuses to sign the ABN.

* For chiropractors, the –AT modifier (which signifies that the patient is under active treatment and that improvement is expected) is only used with the procedure codes 98940, 98941 and 98942.

* With the new changes in effect, the –GA modifier can only be used with procedure codes 98940, 98941 and 98942.

Billing With E & M code

E&M is necessary when performing the initial exam. An E&M service may once again be necessary if there is a change in condition or treatment protocol.

 It is not appropriate to bill for routine scheduled E&M service (every 12 days of treatment).

Use modifier 25 to identify the E&M service separately when performed with CMT.

Documentation must be complete as to the level of E&M services provided according to CPT® guidelines.

CMT codes include a pre-manipulation patient assessment component for each visit, which must be supported by appropriate documentation. Therefore, it is not appropriate to bill an E&M service with each CMT service. If billed inappropriately, the E&M service will be denied as provider liable.

It is appropriate to bill for the CMT and E&M service if one of the following has occurred: • A new patient visit • An established patient visit. The established patient must have a new condition, new injury, aggravation, or exacerbation which warrants further examination above and beyond what is included in CMT services

Payment for manual manipulation of the spine is limited to one manipulation per day and may not exceed 12
manipulations per calendar year. Effective for dates of service on or after January 1, 2005, North Dakota Medicaid
will allow reimbursement to chiropractors for Evaluation and Management (E/M)office and other outpatient
Services – New Patient (99201-99203). These E/M services may be billed in addition to the chiropractic manipulative
treatment (98940-98942) ONLY when the patient has not received any professional (face-to-face) services from the
chiropractor, or another chiropractor of the same group practice, within the past three years.


Background

In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service (FFS) program reported a 54 percent error rate on claims for chiropractic services. The majority of thoseerrors were due to insufficient documentation or other documentation errors.

Medicare coverage of chiropractic services is specifically limited to treatment by means of manual manipulation (that is, by use of the hands) of the spine to correct a subluxation. The patient must require treatment by means of manual manipulation of the spine to correct a subluxation, 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. Additionally, manual devices (that is, 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.

Chiropractors are limited to billing three Current Procedural Terminology (CPT®) codes under Medicare: 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), and 98942 (five regions).When submitting manipulation claims, chiropractors must use an acute treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation. The AT modifier, when applied appropriately, should indicate expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.

Documentation requirements

The Social Security Act states that “no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the  mounts are being paid or for any prior period..

Medical record must document:
1. A complaint involving at least three spinal regions;
2. an examination of the corresponding spinal regions; AND
3. a diagnosis and manipulative treatment of conditions involving at least three spinal regions.
Claim must record a diagnosis codes (ICD-9) in all the applicable regions

Medicare Advantage Policy and Medicare Cost Plan

Medicare coverage of chiropractic services is specifically limited to treatment by means of manual manipulation of the spine to correct a subluxation.

Chiropractors are limited to billing three Current Procedural Terminology (CPT) codes under Medicare: 98940, 98941and 98942 When submitting manipulation claims, chiropractors must use an Acute Treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation. The AT modifier, when applied appropriately, should indicate expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.

Medicare does not cover chiropractic treatment to extraspinal regions (98943) which includes the head, upper and lower extremities, rib cage and abdomen

General Guidelines

All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors. A valid diagnosis is the most appropriate ICD-9-CM code that is supported by subjective symptoms, physical findings, and diagnostic testing/imaging (if appropriate)…

Documentation should be recorded on the day of the patient visit and include all of the following:

1. a subjective record of the patient complaint i.e., location, quality, and intensity

2. physical findings to support manipulation in a region or segment e.g., regional/segmental asymmetry or misalignment,
range of motion abnormality, soft tissue tone and/or tenderness characteristics

3. assessment of change in patient condition, as appropriate

4. a record of the specific segments manipulated 98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions Documentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT).

98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions Documentation must support that manipulative treatment occurred in three to four regions of the spine (region as defined by CPT) and one of the following:

1. validated diagnoses for three or four spinal regions

2. validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and  segmental findings 98942 Chiropractic manipulative treatment (CMT); spinal, five regions Documentation must support that manipulative treatment occurred in five regions of the spine (region as defined by CPT) and one of the following:

1. validated diagnoses for five spinal regions

2. validated diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings

3. validated diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings 98943 Chiropractic manipulative treatment (CMT); extraspinal, one to five regions