Medicare Guides

National policy limits the coverage of chiropractic services to the “hands-on” manual manipulation of the spine (98940, 98941, or 98942) for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943, CMT, extraspinal, one or more regions, is not a Medicare benefit. 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.

Subluxation must be the primary diagnosis for Medicare claims. 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. These diagnoses will range from M99.00 to M99.05 (some states may allow M99.10 to M99.15)

A subluxation may be demonstrated by an x-ray or by physical examination, as described below.

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:
P – Pain/tenderness evaluated in terms of location, quality, and intensity;
A – Asymmetry/misalignment identified on a sectional or segmental level;
R – 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
T – 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.
Specific vertebrae must be identified not just a region. i.e. must be C5, T4, T12 and not the “cervical spine”. However cervicothoracic and lumbosacral would be acceptable as those identify specific levels.

P: PAIN AND TENDERNESS
Identify using one or more of the following:
Observation: You can document, by personal observation, the pain that the patient exhibits during the course of the examination. Note the location, quality, and severity of the pain.
Percussion, Palpation, or Provocation: When examining the patient, ask them if pain is reproduced, such as, “Let me know if any of this causes discomfort.”
Visual Analog Type Scale: The patient is asked to grade the pain on a visual analog-type scale from 0-10.
Audio Confirmation: Like the visual analog scale, the patient is asked to verbally grade their pain from 0-10.
Pain Questionnaires: Patient questionnaires, such as the McGill pain questionnaire or an in-office patient history form can be used for the patient to describe their pain.

A: ASYMMETRY/MISALIGNMENT
Identify on a sectional or segmental level by using one or more of the following:
Observation: You can observe patient posture or analyze gait.
Static and Dynamic Palpation: Describe the spinal misaligned vertebrae and symmetry.
Diagnostic Imaging: You can use x-ray, CAT scan, and MRI to identify misalignments.

R: RANGE OF MOTION ABNORMALITY
Identify an increase or decrease in segmental mobility using one or more of the following:
Observation: You can observe an increase or decrease in the patient’s range of motion.
Motion Palpation: You can record your palpation findings, including listing(s). Be sure to record the various areas that are involved and related to the regions manipulated.
Stress Diagnostic Imaging: You can x-ray the patient using bending views.
Range of Motion Measuring Devices: Devices such as goniometers or inclinometers can be used to record specific measurements.

T: TISSUE, TONE CHANGES
Identify using one or more of the following:
Observation: Visible changes such as signs of spasm, inflammation, swelling, rigidity, etc.
Palpation: Palpated changes in the tissue, such as hypertonicity, hypotonicity, spasm, inflammation, tautness, rigidity, flaccidity, etc. can be found on palpation.
Use of Instrumentation: Document the instrument used and findings.
Tests for Length and Strength: Document leg length, scoliosis contracture, and strength of muscles that relate.

The patient must have a significant health problem in the form of a neuromusculoskeletal condition (Secondary diagnosis) necessitating treatment. The manual manipulative treatment must have a direct therapeutic relationship to the patient’s condition and provide a reasonable expectation of recovery or improvement of function. Many (most) states require this diagnosis to follow the subluxation. Meaning diagnosis A (block 21 of the CMS 1500 form) would be subluxation and diagnosis B a neuromusculoskeletal diagnosis. Each state will have its proprietary list of secondary diagnoses allowed. See the corresponding states below, which have the required secondary diagnoses for each. Note some states only require a subluxation on the claim form but do require a secondary as part of the patient notes and file.

Visit Limits
Medicare does not have a certain number of treatments that will automatically be covered. The need for service should be based upon the reasonableness and necessity of each individual patient encounter and not based on a specific “covered” number. The secondary diagnosis severity plays a role as it can identify severity. See secondary diagnosis for each state as some do categorize diagnosis via severity form short term to long term care Medicare will determine the medical necessity needs of care based on the secondary modifying and tertiary diagnoses, acuity of the condition and the reasonableness that the care is affecting a positive functional change.

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such a 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 decrease 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.

1. Acute: 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: 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.

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 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 temporarily marked deterioration of the patient’s condition due to a 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.

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.

-AT Active/Corrective Treatment
All chiropractic claims submitted to Medicare must have the modifier AT appended to the manipulation code (98940 AT) to indicate that services are deemed by the provider as medically necessary. If you do not add this modifier, your care will automatically be considered maintenance and will be denied. The use of the AT does not guarantee that Medicare will automatically consider care as medically necessary. The use of AT is to indicate chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition. An AT may also be used in a chronic condition 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.

GY Excluded Services (statutorily)
GY identifies services and supplies that are statutorily excluded from Medicare coverage. For chiropractic since only spinal manipulation is a covered benefit by Medicare, all other services are excluded. This means all codes except 98940, 98941, & 98942 will be appended with modifier GY. These services are the liability of the insured (some secondary policies may also cover these services).The use of these modifiers indicates that a denial of services is anticipated and the patient has not signed an ABN. A waiver is not needed for services that are not covered under Medicare due to statutory exclusions, it is suggested that providers inform beneficiaries of the likelihood of a claim denial as a courtesy and to prevent future animosity and/or failure for the patient to pay for these services.Chiropractic physicians are not required to bill Medicare for excluded services unless billing for a denial to submit to a secondary carrier. When excluded services are billed with GY the explanation of benefits (EOB) noting those services as “patient responsibility -PR.”If you have a patient that clearly understands that services excluded are not paid by Medicare and they are subsequently fully liable, not billing those services Medicare is allowed. But should you have a patient that needs to see an EOB to understand their responsibility then those services would be billed and have GY.GP Services are delivered under an outpatient physical therapy plan of care.Even though therapy services are statutorily non-covered in Medicare, the “claim hard-code editing” does not have any exclusions for certain specialties, this means chiropractors will need to report the appropriate therapy modifier (GP) with physical medicine codes in order to receive the appropriate denial for secondary insurance purposes.

This means on claims with physical medicine services billed to Medicare it will now require both modifiers GP and GY (excluded service) to be reported. If the modifiers are not present the code will be denied with no patient responsibility meaning a secondary payer will make no payment.

For example 97012 GP GY

Note the order of the modifiers does not matter and you can use GP GY or GY GP.

GX Excluded Services (statutorily) With Waiver on File
GX identifies services and supplies that are statutorily excluded from Medicare coverage and a waiver (Advanced Beneficiary Notice) is on file. This waiver is a signed document wherein the patient signs and understands that the services are excluded and not covered by Medicare. The result of this modifier is the same as GY.

GA Advanced Beneficiary Notice Has Been Provided
Indicates the expected denial that an item or service is not reasonable and necessary and for chiropractic, this would be utilized for spinal manipulation. When it is determined that manipulation will be or is likely to be denied the patient must be informed prior to receiving the service, by having the patient sign and read the Advanced Beneficiary Notice (ABN. Once this has been done those services should be billed with the Modifier GA (98941-GA) which indicates that the form has been signed and is on file in the patient’s chart. Medicare will deny these services but will afford patient responsibility. Note if option 2 is chosen on the ABN Medicare needs not be billed for the services and the patient is simply responsible. The presence or absence of this modifier does not influence Medicare’s determination for payment. If Medicare determines that the service is not payable, the claim denial is under a “medical necessity denial.”

National policy limits the coverage of chiropractic services to the “hands-on” manual manipulation of the spine (98940, 98941, or 98942) for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943, CMT, extraspinal, one or more regions, is not a Medicare benefit. 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.

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