CHIROPRACTORS BILLING FOR PHYSICAL THERAPY

Chiropractors billing for physical therapy services (CPT codes 97001–97799 and HCPCS code G0283) must bill with the appropriate modifier.

* GN – Services delivered under an outpatient speech-language pathology plan of care.

* GO – Services delivered under an outpatient occupational therapy plan of care.

* GP – Services delivered under an outpatient physical therapy plan of care.

Even though physical therapy billed by a chiropractor is a program exclusion, if one of the above modifiers is omitted from any of the codes referenced, the service will be rejected. This rejection would require the claim to be corrected and resubmitted.

CODING GUIDELINES

* The level of subluxation must be specified on the claim and must be listed as the primary diagnosis, i.e., cervical region (7391). The neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis.

* Non-covered services provided by a chiropractor need not be billed to Medicare unless the patient requests the services be billed to obtain a denial for his supplemental insurance. The chiropractor may bill the services with specific procedure codes for the non-covered services, e.g., X-rays, laboratory tests, physical examinations or physical therapy. One exception to this situation exists: A chiropractor will still be required to bill Medicare for manipulations that exceed the norm and maintenance therapy.

CLAIM REQUIREMENTS

* The initial date of treatment must be documented in Item 14 of the CMS-1500 claim form or the electronic equivalent.

* If the subluxation is demonstrated by an X-ray, the X-ray date must be placed in Item 19 of the CMS-1500 claim form or the electronic equivalent.

Complete claim form instructions can be found at:

http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

Chiropractic services CPT code 98940, 98941, 98942

Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.

Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. 

Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per month and 30 chiropractic manipulation services per beneficiary per year. 

Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. 

Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record. Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

Twelve (12) chiropractic manipulation treatments for Group A diagnoses.

Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.

Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.

Thirty (30) chiropractic manipulation treatments for Group D diagnoses.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.

As published in CMS IOM, Pub. 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

Safe and effective.

Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).

Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member. Furnished in a setting appropriate to the patient’s medical needs and condition. Ordered and furnished by qualified personnel. One that meets, but does not exceed, the patient’s medical need. At least as beneficial as an existing and available medically appropriate alternative.

CPT/HCPCS Codes

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) 

require the use of short CPT descriptors in policies published on the Web. 98940©

Chiropractic manipulation

98941©

Chiropractic manipulation

98942©

Chiropractic manipulation

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:

Billing and Coding Guide

This policy describes Optum’s requirements for reimbursement of CPT codes 98940, 98941, 98942 (Spinal Chiropractic Manipulative Treatment) and 98943 (Extraspinal Chiropractic Manipulative Treatment).

The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.

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). 

Modifier -51 (Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940- 98943). According to “The CPT® Assistant” [December 2013], these are separate and distinct procedures and the use of modifier 51 does not apply. 

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 

CPT Code Description Documentation Requirement

98940 Chiropractic manipulative treatment (CMT) involving one to two spinal regions Medical record must document:

1. A complaint involving at least one spinal region;

2. an examination of the corresponding spinal region(s); AND

3. a diagnosis and manipulative treatment of a condition involving at least one spinal region.

Claim must record a diagnosis code (ICD-9) in the applicable region(s).

NCCI Edit

The below codes would not be paid separately if submitted with CPT code 98940 , Use appropriate Modifier.

64461 64463 64486 64487 64488 64489 95831 95832

95833 95834 95851 95852 96361 96366 96367 96368

97112 97124 97140 98926 98927 98928 98929 99201

99202 99203 99204 99205 99211 99212 99213 99214

99215 99217 99218 99219 99220 99221 99222 99223

99224 99225 99226 99231 99232 99233 99234 99235

99236 99238 99239 99281 99282 99283 99284 99285

99291  99304 99305 99306 99307 99308 99309 99310

99315 99316 99318 99324 99325 99326 99327 99328

99334 99335 99336 99337 99341 99342 99343 99344

99345 99347 99348 99349 99350 99455 99456 99460

99461 99462 99463 99465 99466 99468 99469 99471

99472  99475 99476 99477 99478 99479 99480 99485

99495  99496 99497 G0380 G0381 G0382 G0383 G0384

G0463  

Primary Diagnosis Codes Covered for: 739.0–739.5

Non-allopathic lesions, not elsewhere classified

Secondary Diagnosis Codes

Group A Diagnoses Covered for: 307.81

Tension headache

719.48*

Pain in joint, other specified sites

Note: When using 719.48*, you must specify spine as the site.

723.1

Cervicalgia

724.1–724.2

Other and unspecified disorders of back

724.5

Backache, unspecified

724.8

Other symptoms referable to back

728.85

Spasm of muscle

784.0

Headache

Group B Diagnoses Covered for: - 720.1

Spinal enthesopathy - 721.0–721.2

Spondylosis and allied disorders (arthritis, osteoarthritis, spondyloarthritis) - 721.6

Ankylosing vertebral hyperostosis - 721.90–721.91

Spondylosis of unspecified site - 724.79

Disorders of coccyx, coccygodynia - 729.1

Myalgia and myositis, unspecified - 729.4

Fasciitis, unspecified -  846.0–846.3

Sprains and strains of sacroiliac region - 846.8

Sprains and strains of other specified sites of sacroiliac region - 847.0–847.4

Sprains and strains of other and unspecified parts of back

Group C Diagnoses Covered for: 353.0–353.4

Nerve root and plexus disorders - 353.8

Other nerve root and plexus disorders - 722.91–722.93

Other and unspecified disc disorder - 723.0

Spinal stenosis in cervical region - 723.2–723.5

Other disorders of cervical region

Group D Diagnoses Covered for: 721.3

Lumbosacral spondylosis without myelopathy - 721.41–721.42

Lumbosacral spondylosis with myelopathy - 721.7

Traumatic spondylopathy - 722.0

Displacement of cervical intervertebral disc without myelopathy - 722.10–722.11

Displacement of thoracic or lumbar intervertebral disc without myelopathy - 722.4

Degeneration of cervical intervertebral disc - 722.51–722.52

Degeneration of thoracic or lumbar intervertebral disc - 722.6

Degeneration of intervertebral disc site unspecified - 722.81–722.83

Postlaminectomy syndrome - 724.01–724.03

Spinal stenosis, other than cervical - 724.3–724.4

Other and unspecified disorders of back - 724.6

Disorders of sacrum, ankylosis - 738.4

Acquired spondylolisthesis - 756.11–756.12

Anomalies of spine - 839.01–839.08

Other, multiple and ill-defined dislocations, cervical vertebra, - 839.20–839.21

Other, multiple and ill-defined dislocations, thoracic and lumbar vertebra, closed - 839.41–839.42

Other, multiple and ill-defined dislocations, other vertebra, closed - 953.0–953.4

Injury to nerve roots and spinal plexus

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request. Please see Medicare Benefit Manual sections referenced above for national documentation requirements for Medicare payment of chiropractic services.