Medicare Chiropractic Billing Policies Revised
Stephen Barrett, M.D.
The Center for Medicare and Medicaid Services (CMS) has revised its requirements for chiropractic billing of "active/corrective" treatment and "maintenance" therapy . Under the Medicare program, active therapy (AT) is a course of treatment that provides "reasonable expectation of recovery or improvement of function" whereas maintenance therapy is defined as:
A treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to 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.
Under Medicare, chiropractic maintenance therapy is not considered medically reasonable or necessary and has never been a covered service . The 2003 Improper Medicare FFS Payments report indicates that chiropractors filed claims incorrectly 30.6% of the time and had the highest compliance error rate among the professions whose services are covered . The new policy was established with the hope that specifying which claims are for active/corrective therapy and which are for maintenance therapy will enable more accurate billing and facilitate the claims review process.
Under Medicare, 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. No other service furnished or ordered by chiropractors are covered. In order for a treatment program to be considered active therapy (AT):
- The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment,
- 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.
Medicare regulations further describe "subluxations" as:
- 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.
Claims for spinal manipulation are billed with procedure codes 98940, 98941, or 98942. As of October 4, claims must include the AT modifier (e.g., 98940-AT) if active/corrective treatment is performed or no modifier if maintenance therapy is performed. Every claim for chiropractic active/corrective treatment with or without the AT modifier will continue to be denied if the services exceed frequency limits of "reasonable and necessary" services as defined by contracting that reviews the claims. The policy manual also notes:
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 3 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.
Much of the problem with chiropractic Medicare claims is related to the way the law covering their services was written . In 1972, in response to vigorous lobbying by chiropractors, Congress called ordered limited coverage of chiropractic services under Medicare. The law, which took effect in 1973, called for payment for the treatment of "subluxations demonstrated by x-rays to exist."  A few weeks after the law was passed, Doyl Taylor, head of the AMA Department of Investigation, told me that when chiropractic inclusion appeared inevitable, the "subluxation" language was inserted with the hope of preventing chiropractors from actually being paid. The idea's originator thought that because chiropractic's traditional (metaphysical) "subluxations" were visible only to chiropractors, this provision would sabotage their coverage. After the law was passed, however, two things happened to enable payment. First, chiropractors held a consensus conference that redefined "subluxations" to include common findings that others could see. Second, according to Taylor, the government officials responsible for interpreting the new law "decided that Congress intended chiropractors to be paid for something." The regulators then defined subluxation as "an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae demonstrable . . . to individuals trained in the reading of x-rays" and stipulated that the "primary diagnosis" must be a subluxation.
The best strategy for patients who undergo chiropractic care for back pain is to stop going when they feel better. However, many chiropractors advise lifetime periodic spinal examinations and adjustments for what they call "preventative maintenance." Because "maintenance care" lacks a plausible rationale and has never been proven beneficial, insurance companies do not knowingly pay for it. The new Medicare regulations are an attempt to make it simpler to identify "maintenance care" so claims for it can be denied automatically.
- Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy. Change request 3449, Pub 100-02 Medicare Benefit Policy. Center for Medicare Services, Sept 3, 2004.
- Chiropractors' services. Chapter 15, section 30.5, Medicare Benefits Policy Manual (Pub 100-02).
- FY 2003: Improper Medicare FFS Payments. Centers for Medicare and Medicaid Services, Nov 19, 2003.
- Barrett S. Some notes on subluxations and Medicare. Quackwatch, Nov 22, 1998.
- Social Security Amendments of 1972 (Public Law 92-603), October 30, 1972, pp. 123-134.
This article was posted on October 2, 2004.