Understanding the Medicare Meaning of Function

I have written several articles in the past few years about Medicare documentation, explaining that it is pain-based and not subluxation-based. The purpose for writing these papers is to help DCs navigate the murky waters of properly documenting the treatment of Medicare patients.

I think the confusion exists because most of the individuals who teach documentation classes do not explain that to properly understand what Medicare wants, we must read the Medicare Benefits Policy Manual (MBPS) and local coverage determination (LCD) provided to us by the regional Medicare contractor to which we send our bills. Without reading the LCD, you have to trust someone else's interpretation. As opposed to trusting me, I suggest you read your LCD and compare it to what I have written. This is not complicated, as the LCD is only about five pages worth of reading.

Consider this important question: Do you know what Medicare says about function? Think about this for a moment. Section 240.1.3 of the 2013 MBPS tells us precisely how to interpret the term function:

• 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.
• 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.

Notice in the first bullet that the patient must have a significant health problem in the form of a neuromusculoskeletal condition. This refers to the ICD-9 and soon-to-be ICD-10 diagnosis code that specifically speak to painful spinal conditions listed in each LCD. In other words, Medicare will not pay for manipulation of the spine due to low back pain coming from an aortic aneurysm. The 739 code just tells Medicare the problem is in the spine and likely responsive to manipulation.

Functional improvement refers to recovery from disability. We are required to outline in the patient record what recovery will look like by providing a list of treatment goals that address a patient's functional loss related to the performance of specific activities. We also must monitor disability, or loss of function, by using validated outcome assessment tools (OATs). Examples of appropriate OATs include the Neck Bournemouth Questionnaire, Back Bournemouth Questionnaire, Neck Disability Index, and Oswestry Low Back Pain Disability Questionnaire. These tools track both pain and disability, as it is nearly impossible to have disability due to a painless spinal condition. In other words, pain and a loss of function go hand-in-hand.

The reason someone from Medicare might state they are more concerned about function is because one can still have pain and not be limited in the performance of any activities, and have no disability according to an outcome assessment tool. When this is the case, Medicare will not pay for continued manipulations, even though pain may still be present.