CHIROPRACTIC CPT code 98940, 98941, 98942, 98943

INTRODUCTION TO CHIROPRACTIC SERVICES

A chiropractor must be licensed or legally authorized to furnish chiropractic services by the state or jurisdiction in which the services are furnished. In addition, a licensed chiropractor must meet uniform minimum standards to be considered a physician for Medicare coverage. 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.

If a chiropractor orders, takes or interprets an X-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the X-ray can be used for documentation. However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor.

Chiropractic service, which is eligible for reimbursement, is specifically limited by Medicare to the treatment by means of manual manipulation (i.e., by use of the hands or use of manual devices that are hand-held, with the thrust of the force of the device being controlled manually) of the spine for the purpose of correcting a subluxation. Other services such as lab tests, X-rays, nutritional supplements, modalities, traction, office visits, examinations, supports, etc., are services that Medicare will not consider for payment when performed by a chiropractor.

Payment is based on the physician fee schedule. The fee schedule can be found online at:

http://www.trailblazerhealth.com/Payment/Fee Schedules/Default.aspx

HCPCS CODES

98940© Chiropractic manipulation

98941© Chiropractic manipulation

98942© Chiropractic manipulation

98943© Chiropractic manipulation

Note: CPT code 98943©, CMT, extraspinal, one or more regions, is not a Medicare benefit.

Chiropractic three CPT CODES - 98940, 98941, 98942 with AT modifer

procedure code and description

98940-  - average fee payment-$20 - $30

98941-Chiropract manj 3-4 regions  - average fee payment- $40 - $50

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.

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.