Chiropractic

Published 09/21/2023

Yes. Claims for diagnostic radiology procedures must be submitted with the name, National Provider Identifier (NPI) and applicable provider qualifier of the provider who ordered the procedure, even though these services are non-covered when ordered or performed by a chiropractor. Radiology procedures submitted without this provider information will be rejected as unprocessable.

Also, non-covered radiology procedures should be billed with a HCPCS modifier GY (statutorily non-covered). Failure to bill the GY HCPCS modifier may result in a "provider not eligible to order/refer" denial, instead of a non-covered service denial.

Instructions for reporting the ordering/referring provider on paper and electronic claims can be found in Items 17 (a-b) of the Interactive CMS-1500 Claim Form Tool.

Last Reviewed: 9/21/2023

Therapy services provided by a chiropractor, although non-covered, must be submitted according to therapy guidelines. Therefore, please be sure to include one of the therapy modifiers defined below. Therapy services submitted without the appropriate therapy modifier, including services submitted with HCPCS modifier GY, will be rejected as unprocessable.

  • HCPCS modifier GN — Services delivered under an outpatient speech-language pathology plan of care
  • HCPCS modifier GO — Services delivered under an outpatient occupational therapy plan of care
  • HCPCS modifier GP — Services delivered under an outpatient physical therapy plan of care

A list of codes that require therapy modifiers is available on the CMS website.

Last Reviewed: 9/21/2023

An Advance Beneficiary Notice (ABN) should only be issued if the provider believes that Medicare may not cover a service because it is not medically reasonable and necessary.

An ABN cannot be issued for services that are being billed with the HCPCS modifier AT. The AT HCPCS modifier serves as an indication that the chiropractor is providing active/corrective treatment to address an acute or chronic subluxation; the modifier may not be submitted when services meet the definition of maintenance therapy.

Additionally, an ABN cannot be issued solely because documentation may not meet Medicare’s guidelines. Without all required documentation, our clinical reviewers cannot establish whether the service rendered was medically necessary. If the service is not documented properly, the claim will deny as contractual obligation, and the beneficiary cannot be billed.

Resources

Last Reviewed: 9/21/2023

Notifiers are required to issue Advance Beneficiary Notices (ABNs) when an item or service is expected to be denied based on one of the provisions in the Medicare Claims Processing Manual Chapter 30 §50.2. This may occur at any one of three points during a course of treatment which are initiation, reduction and termination, also known as "triggering events."

Initiations
An initiation is the beginning of a new patient encounter, start of a plan of care, or beginning of treatment. If a notifier believes that certain otherwise covered items or services will be non-covered (e.g., not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care.

Example: Mrs. S. asks her physician for an EKG because her sister was recently diagnosed with atrial fibrillation. Mrs. S. has no diagnosis that warrants medical necessity of an EKG but insists on having an EKG even if she has to pay out of pocket for it. The physician’s office personnel issue an ABN to Mrs. S. before the EKG is done.

Reductions
A reduction occurs when there is a decrease in a component of care (i.e., frequency, duration, etc.). The ABN is not issued every time an item or service is reduced. But, if a reduction occurs and the beneficiary wants to receive care that is no longer considered medically reasonable and necessary, the ABN must be issued prior to delivery of this non-covered care.

Example: Mr. T is receiving outpatient physical therapy five days a week, and after meeting several goals, therapy is reduced to three days per week. Mr. T wants to achieve a higher level of proficiency in performing goal-related activities and wants to continue with therapy five days a week. He is willing to take financial responsibility for the costs of the two days of therapy per week that are no longer medically reasonable and necessary. An ABN would be issued prior to providing the additional days of therapy weekly.

Terminations
A termination is the discontinuation of certain items or services. The ABN is only issued at termination if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary.

Example: Ms. X has been receiving covered outpatient speech therapy services, has met her treatment goals, and has been given speech exercises to do at home that do not require therapist intervention. Ms. X wants her speech therapist to continue to work with her even though continued therapy is not medically reasonable or necessary. Ms. X is issued an ABN prior to her speech therapist resuming therapy that is no longer considered medically reasonable and necessary.

Period of Effectiveness, Repetitive or Continuous Noncovered Care
An ABN can remain effective for up to one year. Notifiers may give a beneficiary a single ABN describing an extended or repetitive course of noncovered treatment provided that the ABN lists all items and services that the notifier believes Medicare will not cover. If applicable, the ABN must also specify the duration of the period of treatment. If there is any change in care from what is described on the ABN within the one-year period, a new ABN must be given. If, during the course of treatment, additional noncovered items or services are needed, the notifier must give the beneficiary another ABN. The limit for use of a single ABN for an extended course of treatment is one year. A new ABN is required when the specified treatment extends beyond one year.

If a beneficiary is receiving repetitive non-covered care, but the provider or supplier failed to issue an ABN before the first or the first few episodes of care were provided, the ABN may be issued at any time during the course of treatment. However, if the ABN is issued after repetitive treatment has been initiated, the ABN cannot be retroactively dated or used to shift liability to the beneficiary for care that had been provided before ABN issuance.

Resources

Last Reviewed: 9/21/2023

Assessments generally have some degree of both subjective and objective information. Objective measures consist of standardized patient assessment instruments, outcome measurement tools or measurable assessments of functional outcome. This limits the degree of individual interpretation of the parameter being measured.

The Medicare Manual requirement for chiropractic services is to establish a treatment plan to include the following:

  1. Recommended level of care (duration and frequency of visits)
  2. Specific treatment goals and
  3. Objective measures to evaluate treatment effectiveness. Since each subsequent visit requires assessment of treatment effectiveness, the objective measures should be documented each subsequent visit

Examples of objective measures to evaluate goals include:

  • Pain: Pain Scales are a subjective response by the patient. Since this is a recognized assessment parameter by the medical community, pain measures are allowable as objective measures. The examples are using the Visual Analog Scale (VAS) since this is accepted as measures.
    • Baseline: 9 on a scale of 1–10 (VAS)
    • Goal: Decrease pain to 1
    • Today’s score: 5
  • Standing:
    • Baseline: Only able to stand for 20 minutes 
    • Goal: Able to stand for more than 1 hour
    • Today’s measure: Able to stand 30 minutes
  • Range of Motion (ROM):
    • Baseline: Lumbar spine flexion of 53 degrees and extension 11 degrees
    • Goal: Increase lumbar flexion to 80 and extension to 25
    • Today’s measure: Lumbar flexion of 65 degrees and extension 20

The important thing to remember is that regardless of the objective measure a provider chooses to use in evaluating effectiveness, the measure must be addressed and documented for each date of service. For instance if measuring progress by pain reduction, the pain scale measure for the date of service should be documented. When using an ADL goal such as standing for a length of time, the parameter of measure should be how long the patient can stand on the date of service. For this reason having your only measurable goal based on the Oswestry Score may not be practical. If your goal is to decrease the Oswestry by 50 percent, to address it every date of service would require performing the Oswestry each date you see the patient. This in no way negates the value of the Oswestry as an assessment tool. It is a very thorough tool for re-evaluation of a patient’s progress after a series of treatments over time.

Resource: CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, chapter 15 (PDF), section 240.

Last Reviewed: 9/21/2023

If a patient is seen once and no further treatment is necessary at that time, this would be considered an initial visit.

Chiropractic visits are categorized into two types of visits: initial and subsequent. Because this is an initial visit, you would create a treatment plan for the patient, and thoroughly document that the patient will not be back for future treatments. All documentation requirements for an initial visit would apply to this scenario.

Resource: CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, chapter 15 (PDF), section 240

Last Reviewed: 9/21/2023

While not mandated, the Advance Beneficiary Notice (ABN) may be provided to Medicare patients as a courtesy to inform them of their financial responsibility for services that are statutorily excluded from Medicare benefits. Medicare, by law, cannot pay for statutorily excluded services. This includes any service provided by a chiropractor other than manual manipulation (e.g., evaluation and management (E/M) services, physical therapy, nutritional supplements and counseling).

Resource: ABNs and Financial Liability — Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.2.1 (PDF).

Last Reviewed: 9/21/2023

To submit a claim for a non-covered service by a chiropractor, use HCPCS modifier GY to indicate that the service is statutorily excluded from coverage. You may submit both covered and non-covered services on the same claim.

Resource: HCPCS Modifier GY.

Last Reviewed: 9/21/2023


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