The Sep 2015 OIG Report: Medicare and Chiropractic Errors
Written by Editor   
Tuesday, October 27, 2015 10:24 AM

In September of 2015 the Office of the Inspector General (OIG) of the Department of Health and Human Services, a federal agency, released a report highlighting its evaluation of chiropractic claims and questionable and inappropriate payments for chiropractic services. This article looks at the OIG’s statements regarding chiropractic errors.

"Chiropractors treat patients for problems of the musculoskeletal and nervous systems…” states the OIG.  “However, Medicare limits coverage of chiropractic services to manual manipulation treatments to treat subluxation of the spine, which is the dislocation of one or more spinal bones."

"Medicare covers chiropractic services to improve function, which it refers to as ‘active treatment’. Medicare does not cover ‘maintenance therapy,’ which is when further clinical improvement cannot be reasonably expected from ongoing treatment.” 

Even though the threshold for “maintenance therapy” is defined by “further clinical improvement,” the OIG states “we determined that 20 services per beneficiary was the threshold for this measure.  We identified as an outlier any chiropractor whose average number of paid claims per beneficiary exceeded the threshold.” The OIG has arbitrarily and not based upon scientific evidence nor review of medical necessity, determined that “when chiropractic care extends beyond 12 treatments in a year it becomes increasingly likely that individual services are medically unnecessary.”  They use this unscientific standard when determining “questionable treatment."

Also of concern to the OIG is the “payment rate for chiropractic services.”   They state: “chiropractic services have had the highest rate of improper payments among Part B services over the last several years, according to the Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Error Rate Testing (CERT) program.  In fact, from 2010 to 2014, the improper payment rate for chiropractic services increased from 43.9 to 54.1 percent while the overall improper payment rate for Part B services remained between 9.9 and 12.9 percent.”  The CERT program determines the “error rate” through the use of five major error categories.

The five major error categories used by the CERT program are 1) no documentation, 2) insufficient documentation, 3) lack of medical necessity, 4) incorrect coding, and 5) other.  The OIG notes “for chiropractic services, the improper payment rate has increasing resulted from insufficient documentation."

While nowhere in this report does the OIG define what “sufficient documentation” may be, they do point out the minimum requirements for Medicare coverage.  These include the following statements:

“Medicare requires that chiropractic claims have a primary diagnosis of ‘subluxation’ for payment, but there is no diagnosis code that contains the word ‘subluxation.’  CMS has instructed chiropractors to use the diagnosis codes that indicate nonollopathic lesions of the spine.  Medicare Administrative Contractors (MACs) also issue local coverage determinations that define the appropriate diagnosis codes for chiropractic claims billed in their jurisdictions.  Claims for chiropractic services must contain the required diagnosis codes."

Under the new ICD-10 diagnosis coding system there IS now a diagnosis code that contains the word “subluxation.”  Indeed it contains the word “Subluxation complex (vertebral)…” and this is the M99.1x series of codes.  It has been reported by some, however, that this is a traumatic code indicating a “near dislocation” of the vertebra and that it should not be routinely used by the DC.; the “segmental and somatic dysfunction…” code should be used as the equivalent of the 739 ICD-9 series.   However since the chiropractic profession routinely uses “subluxation complex” as primary diagnosis, since, as OIG points out there has not heretofore been a diagnosis code for subluxation, and since there IS a diagnosis code for various vertebral dislocations, the S13 series, it will be interesting to see how CMS will choose to proceed.

The OIG also states:  “Chiropractors use Current Procedural Terminology (CPT) codes to bill Medicare Part B.  Medicare pays only for the three CPT codes for chiropractic manipulative treatment of the spine.  These codes indicate the number of spinal regions treated.”  These are 98940 for treatment of one to two spinal regions; 98941 for treatment of three to four spinal regions; and 98942 for treatment of five spinal regions.

CMS requires that chiropractors use the Active Treatment (AT) modifier on a claim when providing a chiropractic service that is active/corrective therapy and not maintenance therapy, which Medicare does not cover.”  The presence of the AT modifier, however, “may not in all instances indicate that the service is reasonable and necessary."

CMS does not limit the number of chiropractic services that a beneficiary may receive over a given time period.  However, some MACs have issued local coverage determinations that limit the number of chiropractic services per beneficiary per year or that require medical review for services that exceed a certain threshold."

The OIG would lead people to believe that this is 12 services per beneficiary per year, even though they use 20 as their defining threshold for determining outliers, and even though Medicare says that as long as there is appropriate documentation that there is not a numerical limit to the number of chiropractic services that a beneficiary may receive.