Medicare Coverage for Chiropractic Manipulative Treatment (CMT)

Medicare Coverage for Chiropractic Manipulative Treatment (CMT)

Chiropractic Manipulative Treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques. Medicare covers limited chiropractic services when performed by a chiropractor who is licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which the services are furnished. For eligibility as a chiropractor, you can refer, “CMS Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 70.6”. A chiropractor must also meet uniform minimum standards as set forth in the CMS Internet-Only Manual (IOM). In this article, we shared coding guidelines and Medicare coverage for Chiropractic Manipulative Treatment (CMT).

Medicare Coverage

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. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. Most spinal joint problems fall into the categories acute subluxation and chronic subluxation.

The term “physician” under Part B includes a chiropractor who meets the specified qualifying requirements set forth in §30.5 but only for treatment by means of manual manipulation of the spine to correct a subluxation. Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. All other services furnished or ordered by chiropractors are not covered.

No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered under §1861(s)(3) of the Act if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.

Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943). The five extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen.

For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, 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. Modifier AT must only be used when the chiropractic manipulation is “reasonable and necessary” as defined by national policy. Modifier AT must not be used when maintenance therapy has been performed. The need for a prolonged course of treatment should be appropriate to the reported procedure code(s) and medical necessity must be documented clearly in the medical record.

Coding Guidelines

  • The precise level of the subluxation must be listed.
  • The date of the initial treatment or date of exacerbation of the existing condition must be entered in Item 14 of the CMS-1500 form or the electronic equivalent.
  • If using an x-ray as documentation of the subluxation, the date of the x-ray (or existing MRI or CT scan) must be entered in Item 19 of the CMS-1500 form or the electronic equivalent.
  • If an authorized ordering practitioner orders the x-ray, then he/she should enter his/her name in Item 17 of the CMS-1500 form and his/her own NPI number in Item 17a of the CMS-1500 form, or the electronic equivalent, as the ordering physician.
  • The HCPCS modifier AT (acute treatment) must be appended to the chiropractic manipulation code to indicate the manipulation was for medically necessary and reasonable treatment of an acute subluxation or chronic subluxation as defined in national policy and the LCD.
  • 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.
  • For claims submitted to the Part B MAC: All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
  • Procedure codes 98940; 98941; and 98942 Chiropractic manipulative treatment: Spinal; 1-2/3-4; 5 regions) are used to bill chiropractic manipulative treatment.

Medisys Data Solutions is a leading medical billing company providing assistance in complete medical billing and coding functions for various medical specialities. We can guide your chiropractic practice to receive accurate insurance reimbursements from private and government payers. To know more about our chiropractic billing services, contact us info@medisysdata.com/ 302-261-9187

CPT codes, descriptions and other data only are copyright 2022. American Medical Association. All Rights Reserved.

Reference: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57889&ver=3&bc=CAAAAAAAAAAA

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