Modifier and Description
AT – Active Treatment
Provider Action Needed
The Active Treatment (AT) modifier was developed to clearly define the difference between active treatment and maintenance treatment. Medicare pays only for active/corrective treatment to correct acute or chronic subluxation. Medicare does not pay for maintenance therapy. Claims should include a primary diagnosis of subluxation and a secondary diagnosis that reflects the patient’s neuromusculoskeletal condition. The patient’s medical record should support the services you are billing. Related MLN Matters Article SE1601 discusses those medical record documentation requirements.
In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service program reported a 54 percent error rate for chiropractic services. The majority of those errors were due to insufficient documentation/documentation errors. Year after year these error rates appear. CMS is providing an explanation of the AT modifier to assist providers with correctly documenting claims for chiropractic services provided to Medicare beneficiaries. The active treatment (AT) modifier defines the difference between active treatment and maintenance treatment. Effective October 1, 2004, the AT modifier is required under Medicare billing to receive reimbursement for Procedure codes 98940- 98941 , 98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active/ corrective treatment (acute and chronic care). The policy requires the following:
1. Every chiropractic claim for CPT 98940/98941/98942, with a date of service on or after October
1, 2004, should include the AT modifier if active/corrective treatment is being performed; and
2. The AT modifier should not be used if maintenance therapy is being performed. MACs deny chiropractic claims for CPT® 98940/98941/98942, with a date of service on or after October 1, 2004, that does not contain the AT modifier. The following categories help determine coverage of treatment. (See the Necessity for Treatment, Chapter 15, Section 240.1.3, of the Medicare Benefit Policy Manual (pages 226-227)).
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 examination).
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 is the case with an acute condition); however, 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. Both of the above scenarios are covered by CMS as long as there is active treatment which is well documented and improvement is expected.
Maintenance: 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.
Be aware that once the provider cannot determine there is any improvement, treatment becomes maintenance and is no longer covered by Medicare.
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, MACs may deny if appropriate after medical review determines that the medical record does not support active/corrective treatment.
You must place the 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.
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.
You should consider providing the Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary. Chiropractors who give beneficiaries an ABN will place the modifier GA (or in rare instances modifier GZ) on the claim. 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. If the beneficiary decides to receive the service, you must submit a claim to Medicare even though you expect that Medicare will deny the claim and that the beneficiary will pay.
“Since March 3, 2008 CMS has issued one form with the official title “Advance Beneficiary Notice of NonCoverage (ABN)” (form CMS-R-131). A properly executed ABN must use this form for each date an ABN is issued and all the required fields on the form must be completed including a mandatory field for cost estimates of the items/services at issue and a valid specific reason why the chiropractor believes Medicare payment for CMT will be denied on this date for this beneficiary. ABNs should not be issued routinely citing the same reason for each occurrence. One ABN cannot be used with added lines for future dates of services. For additional instructions on the proper completion of the ABN, see http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html on the CMS website.
WHAT ARE HCPCS MODIFIERS?
A modifier comprises two alpha, numeric, or alphanumeric characters reported with a HCPCS code, when appropriate. Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. This includes HCPCS Level I (Physicians’ Current Procedural Terminology [CPT®]) and HCPCS Level II codes. The reporting physician appends a modifier to indicate special circumstances that affect the service provided without affecting the service or procedure description itself. When applicable, the appropriate two-character modifier code should be used to identify the modifying circumstance. The modifier should be placed after the usual procedure code number.
The CPT code book, CPT 2018, lists the following examples of when a modifier may be appropriate, including, but not limited to:
• Service/procedure is a global service comprising both a professional and technical component and only a single component is being reported
• Service/procedure involves more than a single provider and/or multiple locations
• Service /procedure was either more involved or did not require the degree of work specified in the code descriptor
• Service/procedure entailed completion of only a segment of the total service/procedure
• An extra or additional service was provided
• Service/procedure was performed on a mirror image body part (eyes, extremities, kidneys, lungs) and not unilaterally
• Service/procedure was repeated
Modifiers 24, 25, 57, and AI may be appended to evaluation and management services only. Each modifier is listed below with its official definition and an example of appropriate use.
Unrelated Evaluation and Management Service by the Same Physician Or Other Qualified Health Care Professional During a Postoperative Period The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.
Modifier 24 is added to the selected E/M service code to identify the E/M service rendered by the same provider as unconnected and distinct from other services in the patient’s postoperative period.
For ambulance services modifiers, single alpha characters with distinct definitions are paired to form a two-character modifier. The first character indicates the origination of the patient (e.g., patient’s home, physician office, etc.), and the second character indicates the destination of the patient (e.g., hospital, skilled nursing facility, etc.). When ambulance services are reported, the name of the hospital or facility should be included on the claim. If reporting the scene of an accident or acute event (character S) as the origin of the patient, a written description of the actual location of the scene or event must be included
with the claim(s).
D Diagnostic or therapeutic site other than “P” or “H” when these are used as origin codes
E Residential, domiciliary, custodial facility (other than 1819 facility)
G Hospital-based ESRD facility
Almost every segment of the health care industry has been affected by the federal government’s antifraud and abuse campaigns over the last several years. Investigations of hospital billing practices, especially teaching hospitals, flooded the news media with reports of indictments, sanctions, and out-of-court settlements for millions of dollars. With trepidation seeping into all areas of health care, more of the federal government’s charges of fraud and abuse committed by clinical laboratories have been heard nationwide, with tens of millions of dollars being paid back to the government. Home health agencies (HHAs), skilled nursing facilities, and durable medical equipment (DME) companies were then targeted. Finally, physician practices and ambulatory surgery centers (ASCs), in state after state, have been undergoing investigations by the FBI, the Office of Inspector General, and officials from the Centers for Medicare and Medicaid Services (CMS). In June 2000, the OIG released a draft version of a physician compliance guidance document aimed at solo practitioners and small physician groups. The Federal Register of October 5, 2000, disclosed the final version of this compliance guidance. Given that the federal government claims it has recouped inappropriate payments and overpayments and has collected fines totaling, up to this point, several billion dollars, there are no signs that fraud and abuse activities will wane.
This chapter of Optum360 Learning: Understanding Modifiers explains the term “compliance” and provides an overview of the federal government’s current efforts to eradicate fraud, waste, and abuse in health care programs. This chapter also provides the reader with logic trees for each modifier. Logic trees should be used by physicians and facilities as self-auditing tools to help ensure correct modifier usage.