Billing and Coding: Chiropractic Services

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L37254- Chiropractic Services . General Guidelines for Claims submitted to Part A or Part B MAC: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported. Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions. Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate. The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required. Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services. The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny. Documentation Requirements: The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Chiropractic care is focused on the treatment goals outlined in the Plan of Care. A plan of care should be individualized for each patient and should include the following: Recommended level of care (duration and frequency of visits) Specific treatment goals ( with documentation of progress or lack thereof within the clinical records) Objective measures to evaluate treatment effectiveness (with qualitative and/or quantitative measures) The use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment. Therefore, treatment effectiveness must be assessed at appropriate intervals during subsequent visits (objective measurable goals). Specific recommendations (i.e. ‘home program’; life style modifications; etc.) for ongoing amelioration of musculoskeletal complaints should be provided as early in the course of treatment as possible; should be reinforced at each visit; and documented in the medical record. For patients who have not achieved the goals documented in the Plan of Care, the practitioner should conclude the episode of chiropractic care in the last visit by documenting the clinical factors that contributed to the inability to meet the stated goals in the treatment plan. The precise level of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. The level of spinal subluxation must bear a direct causal relationship to the patient's symptoms, and the symptoms must be directly related to the level of the subluxation that has been diagnosed. 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 must discuss this risk with the patient and record this in the chart. The need for a prolonged course of treatment must be clearly documented in the medical record. Treatment should result in improvement or arrest of deterioration of subluxation within a reasonable and generally predictable period of time. 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: Spine or spinal adjustment by manual means; Spine or spinal manipulation; Manual adjustment; and Vertebral manipulation or adjustment. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.1) Documentation Requirements: History 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 (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.2.2). Documentation Requirements: Initial Visit The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination: History as stated above. 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. Evaluation of musculoskeletal/nervous system through physical examination. 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. 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. Date of the initial treatment. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.2.2A) Documentation Requirements: Subsequent Visits The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination: 1. History (an interval history sufficient to support continuing need; document substantive changes) Review of chief complaint; Changes since last visit; System review if relevant. 2. Physical exam (interval; document subsequent changes; a full repeat P.A.R.T. is not expected) 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. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.2.2B) 4. Documentation of how the day’s treatment fits within the plan of care (e.g. “visit 4 of planned 7 treatments”) and any way the treatment plan is being changed. Documentation: X-Ray/CT/MRI An x-ray may be used to document subluxation. The x-ray must have been taken

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