Saturday, 6 September 2014

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:

o 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.

o Furnished in a setting appropriate to the patient’s medical needs and condition.

o Ordered and furnished by qualified personnel.

o One that meets, but does not exceed, the patient’s medical need.

o At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
N/A
Revenue Codes
N/A
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.

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.

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. Documentation must support that manipulative treatment occurred in one or more extraspinal regions (as defined by CPT), and there is a validated diagnosis for one or more extraspinal regions for which manipulation has been shown to be both safe and efficacious per appropriate Optum medical policy.

Billing and Coding Guidelines

The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional  E&M services may be reported separately using modifier “25,” if the patient’s condition requires a significant separately identifiable E&M service, above and beyond the usual pre-service and postservice work associated with the procedure. For purposes of CMT, the five spinal regions referred to are:

• Cervical region (includes atlanto-occipital joint);
• Thoracic region (includes costovertebral and costotransverse joints);
• Lumbar region;
• Sacral region; and
• Pelvic (sacroiliac joint) region.

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).

CPT describes the application of modifier -25 when E/M services are reported in conjunction with CMT procedural codes (98940- 98943), “The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional Evaluation and Management services may be reported separately using the modifier -25, if the patient’s condition requires a significant separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with the procedure.”

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.

• 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.

• Payment for x-rays may not exceed two (2) per year and are limited to radiological examinations of the full spine; the cervical, thoracic, lumbar, and lumbosacral areas of the spine.

• Chiropractic services are billed on paper using the CMS-1500 form, or electronically using the standard 837-P HIPAA transaction.

If a chiropractor reports both a CPT 98940-series service and CPT 97140 on the same date of service, the chiropractor’s medical records must document the differences between the two procedures and that each was conducted on a different anatomical site. To document this, you may use Modifier 59 (Distinct procedural service) when billing for these procedures (i.e., CPT 97140-59).

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

Evaluation & Management and CMT (CPT® codes 99201–99215 with 98940–98943) 

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.

• Periodic re-evaluation to determine if a change in the treatment plan is necessary 

2 comments:

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