Medicare and Chiropractic Care: Document, Document, Document!

Updated: Mar 3



In 2018, the Comprehensive Error Testing Program (CERT) that measures improper payments in the Medicare Fee-For-Service (FFS) program reported a 41 percent error rate on claims for chiropractic services.

Most of those errors were due to insufficient documentation or other documentation errors. Medicare limits coverage of chiropractic services 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 the doctor of chiropractic provides must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

The doctor of chiropractic may use manual devices (that is, those that are hand-held with the thrust of the force of the device being controlled manually) in performing manual manipulation of the spine. However, Medicare makes no additional payment for use of the device, nor does Medicare recognize an extra charge for the device itself.

Doctors of chiropractic 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, doctors of chiropractic 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 used appropriately, should indicate expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.

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.

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.

For more information on the documentation of chiropractic care, refer to the Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services, Section 240 here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.

#Medicare #CERT #FFS #Documentationrequirements

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