The Centers for Medicare and Medicaid Services (CMS) Provider Compliance Group has developed an educational and training program specific to doctors of chiropractic. The public YouTube video, "Improving the Documentation of Chiropractic Services," is a requirement of the Medicare Access and CHIP Reauthorization Act of 2015 and comes on the heels of the latest Office of Inspector General report revealing high rates of improper documentation by DCs, particularly insufficient documentation.
In the 20-minute video, Joseph Christ of the Division of Medical Review and Education/Provider Compliance Group, Center for Program Integrity, answers questions about Medicare documentation requirements for chiropractors. Here's a brief summary of Mr. Christ's presentation:
Medicare coverage of chiropractic services is limited to one type of service: manual manipulation of the spine to correct a subluxation.
A subluxation is defined under Medicare 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."
Medicare covers manual manipulative treatment of the spine for three types of services: treatment for 1-2 regions of the spine during one treatment session; 3-4 regions during one session; or five regions during one session. Documentation must match the specific regions treated (e.g., cervical, thoracic, lumbar = three regions) in order for the claim to be paid.
Medical necessity also must be documented sufficiently for a claim to be paid. "Medicare may only pay for items and services that are 'reasonable and necessary' for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body."
The three components of medical necessity, according to Medicare, are 1) presence of a subluxation that causes a significant NMS condition; 2) subluxation must be demonstrated by either X-ray or physical exam (PART); and 3) documentation of both initial and subsequent visits.
Documentation must describe the associated signs / symptoms, along with the precise area associated with the subluxation for which treatment was performed. Documentation of pain alone, without the location specified, is insufficient.
Medicare also requires documentation of the specific manipulative procedure performed, as well as the patient's response to that procedure / treatment.
Appropriate treatment plans should include three elements: 1) duration / frequency of visits recommended; 2) specific goals of treatment; and 3) objective measures to evaluate treatment effectiveness.
98940, 98941 and 98942 codes that do not include the AT modifier, representing active treatment, will automatically be denied. Medicare only reimburses for active care, not maintenance care / therapy.
Mr. Christ also emphasizes that in many cases, Medicare is denying chiropractic claims for one or more of three easily correctable reasons:
Poorly written documentation (difficult / impossible to read)
No signature on claim form
Lack of response when Medicare requests additional information / documentation
To watch the video in its entirety, click here. For additional information on Medicare documentation requirements and chiropractic documentation issues, read Dr. David Seaman, et al's, article, "The Medicare Hurdle That Continues to Block Our Professional Progress" (April 9, 2012 DC) and Dr. Ronald Short's "Targeting the Bad Apples in the Bunch: Latest OIG Report Outlines Plan to Determine Questionable Billing Claims, Recoup Payments" (Nov. 15, 2015 issue).
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The New Jersey Board of Chiropractic Examiners has made a precedential decision, concurring with the Association of New Jersey Chiropractors' (ANJC) position paper on chiropractic X-ray guidelines. In plain terms, the board ruled, consistent with the ANJC position, that insurance companies cannot use medical X-ray rules or recommendations, like those written by the American College of Radiology (ACR), to decide whether a chiropractor's X-ray was necessary.
For decades, chiropractors have been told the answer to more professional referrals is simple: educate medical doctors about chiropractic. There is some truth in that advice; but it is also incomplete. The modern challenge is not simply getting another healthcare professional to know that chiropractors exist. It is becoming the kind of clinician (and building the kind of professional relationship) that makes collaboration easy and sustainable.
