Novitas, Medicare, and Chiropractic 2014
Monday, July 28, 2014 10:23 AM

As of July 24 Novitas is operating under its new local coverage determination for chiropractic services.  The local determination does not replace, modify or supersede existing Medicare national determinations, payment polices, rules or regulations for chiropractic services.  "Neither Medicare policy rules nor this LCD replace, modify or supersede applicable state statues regarding medical practice or other health practice professions acts, definitions and/or scopes of practice."

"All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations, and rules for Medicare payment for chiropractic services and must properly submit only valid claims for them."  Novitas states "Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules."  The sources below reference a number of online "Internet Only Manuals" (IOMs) for your reference.

Regarding "coverage guidance" Novitas reports "it is not appropriate to bill Medicare for services that are not covered … as if they are covered."  They remind us that when billing for non-covered services that we should use the appropriate modifier code.

Novitas states "Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously."  But they note "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."

Bearing these in mind Novitas states "Medicare will allow put to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulation services per beneficiary per calendar year."  That being said, Novitas notes that "each patient's condition and response to treatment must medically warrant the number of services reported for payment" and they note that not every patient should warrant the maximum number of treatments.

Novitas also states "additionally, Medicare requires the medically necessity for each service to be clearly demonstrated in the patient's medical record."  

As in in the past Medicare recognizes four diagnostic groups "with the groups being displayed in ascending specificity."

For group A diagnoses "Medicare does not expect that substantially more than" 12 chiropractic manipulation treatments would be required.

For group B diagnoses this expectation would include "18 chiropractic manipulation treatments."

For group C diagnoses "24 chiropractic manipulation treatments."

and for group D diagnoses "30 chiropractic manipulation treatments."

 Novitas states" "to be covered under Medicare, a service shall be reasonable and necessary."  Novitas states that this provision is met "if the contractor determines that the service is:

  • safe and effective
  • not experimental or investigational ….
  • appropriate, including duration and frequency that is considered appropriate for the service in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis and treatment of the patient's condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient's medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient's medical needs.
    • At least as beneficial as an existing and available medically appropriate alternative.'

Novitas reminds us again that the only CPT/HCPCS codes are the 98940 through 942 CPT codes describing manipulations for 1-2, 3-4, or 5 regions respectively, and that "if a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary."

"Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942" (see the source information below for more detailed information, but the following will suffice as a summary):

PRIMARY DIAGNOSTIC CODES:  739.0 through 739.5 codes for "nonallopathic lesions"


Group A:  tension headache; pain in joint, specified to "spine"; cervicalgia; pain in thoracic spine; Lumbago; backache unspecified; other symptoms referable to the back; spasm of muscle; and headache.

Group B:  spinal enthesopathy; cervical or thoracic spondylosis without myelopathy; ankylosing vertebral exostosis; spondylosis, site unspecified, with, and without myelopathy; other disorders of coccyx; myalgia and myositis, unspecified; fascists unspecified; lumbosacral or sacrotuberous ligament sprain;  sprain of other specified sites of the sacroiliac region; neck sprain; spain of coccyx.

Group C:  brachial plexus to lumboscral root lesions; other nerve root and plexus disorders; disc disorders of the cervical through lumbar regions; Cervical spinal stenosis; cervicocranial syndrome to cervical torticollis.

Group D:  lumbosacral spondylosis without myelopathy; spondylosis with myelopathy thoracic through lumbar regions; traumatic spondylopathy; displacement of cervical, thoracic or lumbar disc without myelopathy; degeneration of cervical, thoracic, lumbar or lumbosacral disc; degenerative disc, unspecified site; post laminectomy syndrome, cervical through lumbar regions; spinal stenosis thoracic through lumbar region with claudication; thoracic, or lumbosacral neuritis or radiculitis to sciatica; disorders of the sacrum; acquired spondylolisthesis; congenital spyndylolysis to spondylolisthesis; the 839 series of "closed dislocation" from cervical to sacum; injury to cervical nerve root to brachial plexus; injury to lumbosacral plexus; or injury to multiple sites of nerve roots and spinal plexus.

Novitas notes that:

  •  "Documentation supporting medical necessity should be legible, maintained in the patient's medical record and made available to Medicare upon request."
  • "Please see Medicare Benefit Manual  for national documentation requirements ."
  • "A chiropractor must place an AT modified on a claim when providing active/corrective treatment to treat acute or chronic subluxation" (emphasis in original).  BUT Novitas notes "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."
  • "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.  The AT modifier must not be placed on the claim when maintenance therapy has been provided.  Claims without the AT modifier will be considered as maintenance therapy and denied.  Chiropractors who give or receive from beneficiaries an ABN shall follow the instructions … and include a GA (or in rare instances a GZ) modifier on the claim."

While not listed as specifically applying to the Texas Jurisdiction, the A47798 notification notes:

  • "When billing for Chiropractic services:
    • Report the initial treatment phase.
    • Report the date of X-ray if an X-ray is used to demonstrate subluxation. The X-ray film must be available for review upon request.
    • A physical examination may be used to document subluxation if an X-ray is not used. The physical examination must be documented in the medical record and must support the subluxation… .
    • Report the level of subluxation using the appropriate ICD-9-CM code.
    • In addition to reporting the ICD-9-CM code for the level of subluxation, report any other pertinent ICD-9-CM codes.
    • … all treatments must be categorized as either acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either "acute" or "chronic" (e.g., an identifiable re-injury would fall under acute)."

"The following modifiers should be reported with procedure code 98940, 98941, or 98942 as is appropriate to each patient's situation:

  • AT – acute treatment
  • GA – authorization has been provided to notify the beneficiary of the likelihood that services will be denied as not reasonable and necessary under Medicare guidelines.
  • GZ – item or service expected to be denied as not reasonable and necessary"

"Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine. The chiropractor is not required to bill excluded services. However, if the beneficiary requests Medicare be billed, the provider must bill services to Medicare in order to obtain a denial for secondary insurance purposes. The following are examples (not an all-inclusive list) of services excluded from Medicare coverage when performed by a chiropractor; the beneficiary is responsible for payment.

  • Laboratory tests
  • X-rays
  • Office visits (history and physicals)
  • Physiotherapy
  • Traction
  • Supplies
  • Injections
  • Drugs
  • EKGs or any diagnostic study
  • Acupuncture
  • Orthopedic devices
  • Nutritional supplements/counseling
  • Any service ordered by the chiropractor"

"In addition, services will be denied, prospectively as well as retrospectively, when:

  • the contractor determines that the service is not medically reasonable and necessary; and/or
  • the guidelines … are not followed; and/or
  • the medical record does not verify that the service described by the HCPCS code was provided; and/or
  • there exists one of the absolute contraindications; and/or
  • the mechanical or electric equipment, that is used for manipulation does not meet the definition of "manual device" as specified ...; and/or
  • an X-ray or physical exam does not support one of the primary diagnoses listed in the "ICD-9 Codes That Support Medical Necessity" section ...; and/or
  • the service was performed as maintenance therapy; and/or
  • the documentation, in the medical record is lacking the information required under the "Documentation Requirements" section ....
Novitas specifically states in the Local Coverage Article that these are"not intended to be interpreted as reflecting chiropractic scope of practice, but rather reflecting chiropractic coverage under the Medicare program."