ICD-10 codes that support medical necessity for chiropractor services

The chiropractic local coverage determinations (LCDs) for MACs include ICD-10 coding Information for ICD-10 codes that support the medical necessity for chiropractor
services. There may be additional documentation information in your LCD. There are links to the chiropractic LCDs in the Additional information section of this article.

The group 1 (primary) codes are the only covered ICD-10-CM codes that support medical necessity for chiropractor services.

*** Primary: ICD-10-CM codes (names of vertebrae)

*** The precise level of subluxation must be listed as the primary diagnosis.

The groups 2, 3, and 4 ICD-10-CM codes support the medical necessity for diagnoses and involve short, moderate, and long term treatment:

*** Group 2 codes: Category I - ICD-10-CM diagnosis (diagnoses that generally require short-term treatment)

*** Group 3 codes: Category II - ICD-10-CM diagnosis (diagnoses that generally require moderate-term treatment)

*** Group 4 codes: Category III - ICD-10-CM diagnosis (diagnoses that may require long-term treatment) ICD-10 codes that do not support medical necessity are all ICD-10-CM codes not listed in LCDs under ICD-10-CM codes that support medical necessity.



Additional information

If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work.

AT modifier - Description - Use of the modifier in chiropractic billing

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. 

Background

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.


Key points

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.

AMBULANCE MODIFIERS

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

H Hospital

INTRODUCTION

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. 

Therapy and Acupuncture CPT code list

Therapeutic Procedures

Physician or therapist required to have direct (one-on-one) patient contact. The therapeutic procedures, for one or more areas, each 15 minutes interval is as follows:

• 97110 Therapeutic exercises to develop strength and endurance, range of motion and flexibility

• 97112 Neuromuscular reeducation of movement, balance, coordination, kinesthetic senses, posture, and/or proprioception for sitting and/or standing activities

• 97113 Aquatic therapy with therapeutic exercises

• 97116 Gait training (includes stair climbing)

• 97124 Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

• 97140 Manual therapy techniques, one or more regions, each 15 minutes

• 97150 Therapeutic procedure(s), group (2 or more individuals)

• 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

• 97535 Self-care/home management training (e.g., ADL), each 15 minutes


Tests and Measurements (Requires direct on-on-one patient contact)

• 97750 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes

• Orthotic Management and Prosthetic Management

• 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

• 97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes


Acupuncture

• 97810 Without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

• 97811 Without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

• 97813 With electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

• 97814 With electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)


Florida Blue reserves the right to change the contents of the listing in accordance with revisions to industry standards, AMA/CPT guidelines, and with normal annual fee schedule coding updates.

Chiropractic Modalities

• Physical Medicine and Rehabilitation

• CPT Code Description


The application of a modality that does not require direct (one-on-one) patient contact by the provider is as follows:

• 64550 Application of surface (transcutaneous) neuro stimulator

• 97012 Traction, mechanical

• 97014 Electrical stimulation (unattended)

• 97016 Vasopneumatic devices

• 97018 Paraffin bath

• 97022 Whirlpool

• 97024 Diathermy (e.g., microwave)

• 97028 Ultraviolet


Constant Attendance Modalities

The application of a modality that requires direct (one-on-one) patient contact by the provider is as follows:

97032 Electrical stimulation (manual)

97033 Iontophoresis

97034 Contrast baths

97035 Ultrasound

97036 Hubbard tank

Acupuncture CPT CODES 97810, 97811, 97813, 97814

Procedure code and Description


• 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

• 97811: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles

• 97813: Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient


• 97814: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles

Acupuncture: A chiropractic provider may not provide acupuncture services until certified by the Florida Board of Chiropractic Medicine. Acupuncture is reported based on 15 minute increments of personal (face-to-face) contact with the patient, not the duration of acupuncture needle(s) placement. If no electrical stimulation is used during a 15 minute increment, use 97810 or 97811. If electrical stimulation of any needle is used during a 15 minute increment, use 97813 or 97814. Only one code may be reported for each 15 minute increment. Use either 97810 or 97813 for the initial 15 minute increment. Only one initial code is reported per day.

The FEP does not include benefits for acupuncture when performed by a chiropractor.


Covered Services for Medicare Advantage Members:

According to the Centers for Medicare & Medicaid Services (CMS) Internet-only manual, Publication 100-02 Medicare Benefit Policy Manual, chapter 15, section 30.5, chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered. Chiropractors are not limited to any specific procedures and may render services as they feel necessary, but according to CMS guidelines; the benefit will only cover manual spinal manipulation, which includes procedure codes: 98940, 98941, and 98942.


The following procedure code ranges will deny for chiropractors as non-covered services:

• 00100 through 98929

• 98943 through 99607

• A0021 through V5364

Questions and Answers

1 Q: Acupuncture is not covered by Medicare, but can members still have the treatment?

A: Some Medicare Advantage members have a supplemental benefit package with coverage for acupuncture.

2 Q: Does CMS have new limited coverage for acupuncture?

A: A new NCD 30.3.3 Acupuncture for Chronic Lower Back Pain (cLBP) has coverage only for chronic lower back pain, effective January 21,2020. All other acupuncture remains non-covered.

3 Q: Is auricular peripheral nerve simulation covered?

A: The service for auricular peripheral nerve simulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture does not meet the definition of reasonable and necessary under Section 1862(a) (1) of the Act. ANSiStim, E-Pulse, Neurostim system/NSS, P-Stim, and NSS-2

Bridge, other current or future devices when used for the procedure electro-acupuncture or auricular peripheral nerve stimulation, would also be considered a non-covered service. Any ear or auricular electrical devices (e.g., DyAnsys®) are also non-covered by Medicare as electrical acupuncture.

2021 Medicare Product Acupuncture Benefit Changes

Beginning January 1, 2021, two separate benefits, with separate accumulations, will apply to acupuncture services provided to subscribers enrolled with a Medicare Advantage or Platinum Blue (Medicare Cost) plan.

Medicare Eligible Benefit

The Centers for Medicare & Medicaid (CMS) announced that acupuncture for low back pain is a covered benefit beginning in January 2020. Twenty acupuncture (20) visits are covered within a rolling 12-month period. Acupuncture services will only be allowed if billed for diagnosis codes listed in NCD 30.3.3. Providers must accurately point the correct diagnosis to each claim line for dates of service in 2021 to apply the appropriate benefit. Acupuncture services pointed to pain diagnoses other than those in NCD 30.3.3 will process under the Supplemental Benefit described below.

Supplemental Benefit

Blue Cross and Blue Shield of Minnesota (Blue Cross) will offer a supplemental benefit for acupuncture services for physical pain diagnoses other than low back pain. Acupuncture services for diagnoses unrelated to physical pain will not be covered. Providers must accurately point the correct diagnosis to each claim line for dates of service in 2021 to apply the appropriate benefit. This benefit is limited to 20 visits per calendar year.

Reimbursement Allowance

The reimbursement for Medicare eligible acupuncture for Medicare Advantage plans will be as follows:

• Professional claim: the contracted Medicare fee schedule allowance

• Facility claim: contracted Medicare allowance

 The reimbursement for non-Medicare eligible acupuncture for Medicare Advantage plans will be as follows:

• Professional claim: the contracted Medicare fee schedule allowance

• Facility claim: 35% of billed charges based on the provider billing the usual and customary charge

The reimbursement for Medicare eligible acupuncture for Platinum Blue (Medicare Cost) plans will be as follows:

• Professional claim: the contracted Medicare fee schedule allowance

• Facility claim: Medicare is primary, Blue Cross will coordinate based on Medicare processing

The reimbursement for non-Medicare eligible acupuncture for Platinum Blue (Medicare Cost) plans will be as follows:

• Professional claim: the contracted commercial fee schedule allowance

• Facility claim: 100% of billed charges based on the provider billing the usual and customary charge Eligible providers

Must be under supervision of a licensed Physician; Independent Acupuncturists are not covered. Physicians as defined in 1861(r)(1) of the Social Security Act (the Act) may furnish acupuncture in accordance with applicable state requirements.

Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:

• a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and,

• a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or  Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

• Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS required by our regulations at 42 CFR §§ 410.26 and 410.27.

Guideline from BCBS

Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed doctor of acupuncture (D. Ac.) or physician (State of Rhode Island-licensed MD or DO)* only. Acupuncture assistants are not recognized for separate reimbursement and are therefore considered inclusive of the acupuncture reimbursement.

An initial evaluation (99201-99205) is allowed only for new patients. According to CPT guidelines, a new patient is one who has not received any professional services from the physician within the past three years.

The following services are not covered:

** **cupuncture with electrical stimulation;
** **djunctive therapies, such as but not limited to moxibustion, herbs, oriental massage, etc.;
** **cupuncture when used as an anesthetic during a surgical procedure;
** Precious metal needles (e.g., gold, silver, etc.);
** **cupuncture in lieu of anesthesia;
** **ny other service not specifically listed as a covered service.

*Acupuncture services may be rendered by a physician (MD or DO) when the following Rhode Island Department of Health criteria has been met:

2.2 Any physician licensed in Rhode Island under the provisions of Chapter 5-37 who seeks to practice medical acupuncture as a therapy shall comply with the following:

2.2.1 Meet the requirements for licensure as a doctor of acupuncture set forth in the Rules and Regulations for Licensing Doctors of Acupuncture and Acupuncture Assistants promulgated by the Department of Health; or 2.2.2 Successfully complete a course offered to physicians that meets the requirements set forth in these regulations and includes no less than the following:

a) a minimum of three hundred (300) hours of formal instruction;

b) a supervised clinical practicum incorporated into the formal instruction required in subsection 2.2.2(a) (above).

Acupuncture is a covered benefit for those groups who have purchased the acupuncture rider or who have an acupuncture benefit. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable acupuncture benefits/coverage. Rhode Island-mandated benefits do not apply to Plan 65, FEHBP, and Medicare Advantage plans. Selffunded groups may or may not choose to follow state mandate(s).

Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain, to treat various nonpainful disorders, and to alleviate withdrawal symptoms of opioid dependence. Acupuncture has also been used or proposed for a large variety of indications.

Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 2000 years. It involves piercing the skin with needles at specific body sites. The placement of needles into the skin is dictated by the location of meridians. These meridians, or channels, are thought to mark patterns of energy, called Qi (Chi), that flow through the human body. According to traditional Chinese philosophy, illness occurs when the energy flow is blocked or unbalanced, and acupuncture is a way to influence chi and restore balance. Another tenet of this philosophy is that all disorders are associated with specific points on the body, on or below the skin surface.

Several physiologic explanations of acupuncture’s mechanism of action have been proposed including an analgesic effect from release of endorphins or hormones (eg, cortisol, oxytocin), a biomechanical effect, and/or an electromagnetic effect.

There are 361 classical acupuncture points located along 14 meridians, and different points are stimulated depending on the condition treated. In addition to traditional Chinese acupuncture, there are a number of modern styles of acupuncture, including Korean and Japanese acupuncture. Modern acupuncture techniques can involve stimulation of additional non-meridian acupuncture points. Acupuncture is sometimes used along with manual pressure, heat (moxibustion), or electrical stimulation (electroacupuncture). Acupuncture treatment can vary by style and by practitioner, and is generally personalized to the patient. Thus, patients with the same condition may receive stimulation of different acupuncture points.

Scientific study of acupuncture is challenging due to the multifactorial nature of the intervention, variability in practice, and individualization of treatment. There has been much discussion in the literature on the ideal control condition for studying acupuncture. Ideally, the control condition should be able to help distinguish between specific effects of the treatment and nonspecific placebo effects related to factors such as patient expectations and beliefs and the patient-provider therapeutic relationships. A complicating factor in selection of a control treatment is that it is not clear whether all 4 components (ie, the acupuncture needles, the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle) are necessary for efficacy.

CODING Commercial Products

Local providers in the Acupuncture Specialty (053) are able to file only the codes found in this policy.

Providers should not file an E & M service on the same date of service as the acupuncture service unless it meets the definition for use of Modifier -25. The acupuncture codes and services 97810, 97811 include preservice, intra-service and post-service evaluation and management for the typical following factors of history, evaluation, management and chart documentation done as part of the overall daily treatment.

The following CPT codes are covered under the acupuncture rider only:

97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-onone contact with the patient

97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

Evaluation and Management codes are only used for separately identifiable procedures.

99201 Office or other outpatient visit for the evaluation and management of a new patient
99202 Office or other outpatient visit for the evaluation and management of a new patient
99203 Office or other outpatient visit for the evaluation and management of a new patient
99204 Office or other outpatient visit for the evaluation and management of a new patient
99205 Office or other outpatient visit for the evaluation and management of a new patient
99211 Office or other outpatient visit for the evaluation and management of an established patient
99212 Office or other outpatient visit for the evaluation and management of an established patient
99213 Office or other outpatient visit for the evaluation and management of an established patient
99214 Office or other outpatient visit for the evaluation and management of an established patient
99215 Office or other outpatient visit for the evaluation and management of an established patient

The following CPT codes are contract exclusions (non-covered):
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).

CPT Code Description Fee

97810 Acupuncture $25.50

97811 Acupuncture, additional 15 minutes $18.93

97813 Acupuncture with electrical stimulation $27.27

97814 Acupuncture with electrical stimulation, additional 15 minutes $21.46

Billing tips for 98943, 97140, E0720 AND E0730

The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E/M services may be reported separately using modifier 25, if the member’s condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure.

Chiropractic Manipulative Treatment: CMT is a form of manual treatment to influence joint and neurophysiological function.

When similar or identical procedures are performed, but are qualified by an increased level of complexity:

Only the definitive or most comprehensive service performed should be reported

Only one CMT service of the spinal region (procedures 98940-98942) is eligible for payment on a single date of service.

Payment is limited to one clinically indicated and medically necessary physical medicine modality or procedure code per patient, per date of service.

Payment is allowed for one clinically indicated and medically necessary extra spinal manipulation code (i.e., 98943-51) in combination with a spinal manipulation code (i.e., 98940, 98941, or 98942) per date of service.

When multiple procedures are performed at the same session by the same provider, the modifier 51 may be appended to the additional CPT codes (excluding E/M codes).


Physical Medicine and Rehabilitation: The selection of appropriate physical medicine modalities and procedures should be based on the desired physiological response in correlation to the stages of healing. In most conditions or injuries, utilization of one carefully selected modality or procedure in combination with CMT is adequate to achieve a successful clinical outcome.

97140, manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes, will not be separately reimbursed when billed with 98940-98943 (CMT) for the same region. Modifier 59 should be used with 97140 when billed with a CMT code, but performed on a different anatomical region.

It is not appropriate to bill 97124, massage, for myofascial release. For myofascial release, 97140 should be reported and is reimbursable if it is not billed with a CMT code pertaining to the same anatomical region. When reporting or billing for 97112 (neuromuscular reeducation) and 97124 (massage) as well as all other physical medicine modalities and therapeutic procedures, the details of the procedure shall be recorded in the medical record, including clinical rationale, anatomical site, description of service, and time (as required by the selected procedure code).


TENS: When found to be medically necessary, the following codes are reimbursed for TENS when billed under the following codes:

• E0720

• E0730

Documentation requirements for subsequent visits - Chiropractic billing

The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination:

1. History

a. Review of chief complaint;

b. Changes since last visit; and

c. Systems review if relevant.

2. Physical examination

a. Examination of area of spine involved in diagnosis;

b. Assessment of change in patient condition since last visit;

c. Evaluation of treatment effectiveness.


3. Documentation of treatment given on day of visit.


 Necessity for treatment of acute and chronic subluxation

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 examination, as described below.

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 examination 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 tosignificantly 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.

You must place the HCPCS (healthcare common procedure coding system) modifier AT on a claim when providing active/corrective treatment to treat acute or
chronic subluxation. However, the presence of the HCPCS modifier AT may not  in all instances indicate that the service is reasonable and necessary.

Documentation requirements for the initial visit - X RAY and Date of Initial treatment

The following documentation requirements apply for initial visits whether the subluxation is demonstrated by x-ray or by physical examination:


1. History: The history recorded in the patient record should include the following:

*** Chief complaint including the symptoms causing patient to seek treatment;

*** Family history if relevant; and

*** Past medical history (general health, prior illness, injuries, or hospitalizations; medications; surgical history).


2. Present illness: 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.



Note: Symptoms must be related to the level of the subluxation that is 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 that area.

3. Physical exam: Evaluation of musculoskeletal/ nervous system through physical examination. To demonstrate a subluxation based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required and should be documented:

*** P - pain/tenderness: The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation,
provocation, etc. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, and so forth.

*** A - asymmetry/misalignment: Asymmetry/ misalignment may be identified on a sectional or segmental level through one or more of the following: observation (such as,  osture and heat analysis), static palpation for misalignment of vertebral segments, diagnostic imaging.

*** R - range of motion abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, measurement(s).

*** T -tissue tone, texture, and temperature abnormality: Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following  procedures: observation, palpation, use of  instrumentation, test of length and strength.

Note: The P.A.R.T. (pain/tenderness; asymmetry/  misalignment; range of motion abnormality; and tissue tone, texture, and temperature abnormality) evaluation
process is recommended as the examination alternative to the previously mandated demonstration of subluxation by X-ray/MRI/CT for services beginning January 1, 2000. The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).

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. 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 as shown in the following table:


Area of spine     Names of vertebrae    Number of  vertebrae      Short form  or other  name   Subluxation ICD-10 code

Neck Occiput     Cervical  Atlas Axis      7         Occ,  CO  C1-C7   C1  2         M99.00  M99.01

Back         Dorsal or  Thoracic  Costovertebral    12          D1-  D12  T1-T12  R1-  R12  R1-  R12     M99.02
           
Low back      Lumbar          5             L1-L5                M99.03

Pelvis              Ilii, R and L (I, Si)        I, Si                    M99.05

Sacral            Sacrum,  coccyx            S, SC             M99.04


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 in patient’s record.

*** The exact bones may be listed, for example: C 5, 6;

*** The area may suffice if it implies only certain bones such as: occipito-atlantal (occiput and Cl (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; and

*** Motion - limited, lost, restricted, flexion, extension, hypermobility, 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.
X-rays As of January 1, 2000, an X-ray is not required by  Medicare to demonstrate the subluxation. However, an x-ray may be used for this purpose if you so choose.
The x-ray must have been taken reasonably close to (within 12 months prior or three months following) the beginning of treatment. In certain cases of chronic
subluxation (for example, scoliosis), an older X-ray may be accepted if 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 are acceptable evidence if a subluxation of the spine is demonstrated.

5. Treatment plan: The treatment plan should always 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

The patient’s medical record.

*** Validate all of the information on the face of the claim, including the patient’s reported diagnosis(s), physician work (CPT® code), and modifiers.

*** Verify that all Medicare benefit and medical necessity requirements were met.

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

Medicare Coverage of Chiropractic Services

Coverage of chiropractic services is specifically limited to treatment by means of manual manipulation (i.e., by use of the hands) of the spine to correct a subluxation. 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.
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. 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. If you order, take, or interpret an x-ray, or any other diagnostic test, the x-ray or other diagnostic test can be used for documentation, but Medicare coverage and payment are not available for those services. This does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program.

Subluxation May Be Demonstrated by X-Ray or Physician’s Examination


Physical examination

To demonstrate a subluxation based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required:

1. Pain/tenderness evaluated in terms of location, quality, and intensity;

2. Asymmetry/misalignment identified on a sectional or segmental level;

3. Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility); and

4. Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.

Documentation Requirements Must Be Placed in the Patient’s File

Initial Visit

The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. The history includes the following:

a. Symptoms causing patient to seek treatment;

b. Family history if relevant;

c. Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);

d. Mechanism of trauma;

e. Quality and character of symptoms/problem;


f. Onset, duration, intensity, frequency, location, and radiation of symptoms;

g. Aggravating or relieving factors; and

h. Prior interventions, treatments, medications, secondary complaints.



2. Description of the present illness, including:

a. Mechanism of trauma;

b. Quality and character of symptoms/problem;

c. Onset, duration, intensity, frequency, location, and radiation of symptoms;

d. Aggravating or relieving factors;

e. Prior interventions, treatments, medications, secondary complaints; and

f. Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. 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. The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.

5. Treatment Plan should include the following:

a. Recommended level of care (duration and frequency of visits);

b. Specific treatment goals; and

c. Objective measures to evaluate treatment effectiveness.

6. Date of the initial treatment.

7. The patient’s medical record.

• Validate all of the information on the face of the claim, including the patient’s reported diagnosis(s), physician work (CPT code), and modifiers.

• Verify that all Medicare benefit and medical necessity requirements were met.


Subsequent Visits

The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. History

a. Review of chief complaint;

b. Changes since last visit; and

c. Systems review if relevant.

2. Physical examination

a. Examination of area of spine involved in diagnosis;

b. Assessment of change in patient condition since last visit;

c. Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

Necessity for Treatment

Acute and Chronic Subluxation

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 examination, as described above.

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 examination 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.


Medicare Coding and Billing

** The CMS-1500 form (or its electronic equivalent) is how we communicate with our local Part B Medicare Administrative Contractor the services we have performed and why we performed them.
** You are talking to a computer and all that it knows is what you tell it through the numbers that you put on the 1500 Form.
** There are two code sets that are used to communicate information to the MAC.
o ICD-9-CM codes.
o CPT codes.
** ICD-9-CM stands for International Classification of Disease, 9th edition, Clinical Modification.
** We covered diagnosis in another webinar.
** CPT® stands for Current Procedural Terminology®
** The CPT® Code Set is owned by the American Medical Association.
** This is why there is a delay in the implementation of the ICD-10 codes.
** The ICD-10 codes are used both for diagnosis and procedures coding.
** The procedure codes that chiropractors use to bill covered procedures to Medicare are:
o 98940
o 98941
o 98942
** Remember that the only Medicare covered procedure for chiropractors is the adjustment.
** The only reason to bill any other procedure would be at the request of the patient and then only if they have a secondary insurance that would require a denial from Medicare before they paid for the service.

AT Modifier

** “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 an 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.”
** The AT modifier must be on all active treatment services for correction of acute and chronic subluxations.
** If you have a signed ABN on file but are still in active treatment, use the AT,GA modifier combination in that order.
** Do Not use the AT modifier for care that is maintenance in nature. 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. GY Modifier
** The GY modifier is used to indicate that a service is not covered by Medicare
** Use the GY modifier when a patient’s secondary insurance needs a rejection by Medicare before they will pay for a service GZ Modifier
** The GZ modifier is used when you expect Medicare to deny the service and you do not have an ABN form signed.
** Use this modifier when you forgot the ABN.
** Expect an audit if you use this modifier Q6 Modifier
** Services provided by a Locum Tenens physician
** Use this modifier when you have another doctor filling in for you.
** A Locum Tenens doctor can fill in for 60 days.

ICD-10 CODE DESCRIPTION
M99.00 Segmental and somatic dysfunction of head region
M99.01 Segmental and somatic dysfunction of cervical region
M99.02 Segmental and somatic dysfunction of thoracic region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.05 Segmental and somatic dysfunction of pelvic region
M99.10 Subluxation complex (vertebral) of head region
M99.11 Subluxation complex (vertebral) of cervical region
M99.12 Subluxation complex (vertebral) of thoracic region
M99.13 Subluxation complex (vertebral) of lumbar region
M99.14 Subluxation complex (vertebral) of sacral region
M99.15 Subluxation complex (vertebral) of pelvic region

Group 2 codes

G44.1 Vascular headache, not elsewhere classified
G44.209 Tension-type headache, unspecified, not intractable
G44.219 Episodic tension-type headache, not intractable
G44.229 Chronic tension-type headache, not intractable
M24.50 Contracture, unspecified joint
M47.10 Other spondylosis with myelopathy, site unspecified
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.819 Spondylosis without myelopathy or radiculopathy, site unspecified
M47.891 Other spondylosis, occipito-atlanto-axial region
M47.892 Other spondylosis, cervical region
M47.893 Other spondylosis, cervicothoracic region
M47.894 Other spondylosis, thoracic region
M47.895 Other spondylosis, thoracolumbar region
M47.896 Other spondylosis, lumbar region
M47.897 Other spondylosis, lumbosacral region
M47.898 Other spondylosis, sacral and sacrococcygeal region
M48.10 Ankylosing hyperostosis [Forestier], site unspecified
M48.11 Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region
M48.12 Ankylosing hyperostosis [Forestier], cervical region
M48.13 Ankylosing hyperostosis [Forestier], cervicothoracic region
M48.14 Ankylosing hyperostosis [Forestier], thoracic region
M48.15 Ankylosing hyperostosis [Forestier], thoracolumbar region
M48.16 Ankylosing hyperostosis [Forestier], lumbar region
M48.17 Ankylosing hyperostosis [Forestier], lumbosacral region
M48.18 Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal region
M48.19 Ankylosing hyperostosis [Forestier], multiple sites in spine
M54.2 Cervicalgia
M54.5 Low back pain
M54.6 Pain in thoracic spine
M54.89 Other dorsalgia
M54.9 Dorsalgia, unspecified
R51 Headache