MEDICARE INFORMATION PAGE
 
   
This Page is devoted to informing the profession about the expanded-services
of chiropractic in the 2-year Medicare Demonstration project, as well as followup
on Medicare coverage in general. This section is updated regularly.
 
   
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This section was compiled by Frank M. Painter, D.C.
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Medicare Articles & Guideline Information
 
   

The Endless Medicare Saga
First, you might want to catch up on the history (pre 2006) of our professional struggles with Medicare to gain fair coverage for our patients, and to level the playing field with all the other “covered” providers.

Medicare Documentation Guidelines
The American Chiropractic Association
The American Chiropractic Association provides this commentary in order to assist its members to better understand the Medicare PART clinical documentation guidelines. These are Centers for Medicare and Medicaid Services (CMS) guidelines that apply to Medicare only.   However, since these guidelines describe “medical necessity” to Medicare, they should also apply to any other insurer's requirements.


Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic
and Opioid Use in Younger Medicare Beneficiaries

J Manipulative Physiol Ther. 2016 (Mar 28) [Epub ahead of print] ~ FULL TEXT

In this exploratory analysis, we found a strong inverse correlation between the per-capita supply of DCs and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Further, we found a strong inverse correlation between the per-capita spending on CMT and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Based upon our findings, we suggest that Medicare consider promoting a trial of CMT prior to use of conventional medical care for patients with neck or back pain. The rationale for use of CMT prior to medical care is that concurrent medical care might result in opioid prescriptions; however, further study that examines opioid use when CMT and conventional medical care are concurrently provided is warranted.

The Association Between Use of Chiropractic Care and Costs of Care
Among Older Medicare Patients With Chronic Low Back Pain
and Multiple Comorbidities

J Manipulative Physiol Ther. 2016 (Feb 19) [Epub] ~ FULL TEXT

After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided.

Regional Supply of Chiropractic Care and Visits to Primary Care
Physicians for Back and Neck Pain

J Am Board Fam Med. 2015 (Jul);   28 (4):   481–490 ~ FULL TEXT

Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11-14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services.

Chiropractic Care and the Risk of Vertebrobasilar Stroke:
Results of a Case-control Study in U.S. Commercial and
Medicare Advantage Populations

Chiropractic & Manual Therapies 2015 (Jun 16);   23:   19 ~ FULL TEXT

We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.

Deconstructing Chronic Low Back Pain in the Older Adult -
Shifting the Paradigm from the Spine to the Person

Pain Medicine 2015 (May);   16 (5):   881-885 ~ FULL TEXT

Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled [1], and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket. [1-3]   Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected.

Risk of Stroke After Chiropractic Spinal Manipulation in Medicare B
Beneficiaries Aged 66 to 99 Years With Neck Pain

J Manipulative Physiol Ther. 2015 (Feb);   38 (2):  93–101 ~ FULL TEXT

The proportion of subjects with stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33-0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01-1.19).   Among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.

Risk of Traumatic Injury Associated with Chiropractic Spinal
Manipulation in Medicare Part B Beneficiaries Aged 66-99

Spine (Phila Pa 1976). 2014 (Dec 9) [Epub ahead of print]

Among Medicare beneficiaries aged 66-99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.

Chiropractic Use in the Medicare Population: Prevalence, Patterns, and Associations With 1-Year Changes in Health and Satisfaction With Care
J Manipulative Physiol Ther. 2014 (Oct);   37 (8):   542-551 ~ FULL TEXT

This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

The Comparative Effect of Episodes of Chiropractic
and Medical Treatment on the Health of Older Adults

J Manipulative Physiol Ther 2014 (Mar);   37 (3):   143–154 ~ FULL TEXT

This study provides evidence of the comparative effectiveness of chiropractic care relative to medical-only services on the functional health of older adults during acute episodes of back care. Our results are the first to show the importance of examining chiropractic use within an episode of care in traditional practice settings, rather than focusing on visit frequency alone. Moreover, we evaluated the effects of the treatments received during the episodes on ADLs, IADLs, and LBFs, which are critically important measures that inform patients, clinicians, and payers about the benefits and harms of certain treatments relative to others. Given the literature supporting a minimally effective chiropractic treatment level for back problems, this research provides additional support that such therapeutic levels are indeed beneficial in terms of protecting older persons from functional declines and self-rated health over as much as 2 years.

Epidural Steroid Injections:
Are long-term Risks Worth Short Term Benefits?

ACA News ~ February 2014

While it is true that epidural steroid injections (ESI) are not FDA approved, Medicare, Medicaid, workers’ compensation and most other insurers continue to pay hundreds of millions of dollars per year for this controversial procedure.   Ironically, on every vial of Kenalog (a popular steroid used for epidural injections) there is actually a warning against its use for epidural injections, yet proceduralists continue to use it.

Our No. 1 Medicare Documentation Error
Dynamic Chiropractic ~ January 15, 2014

We have all heard that chiropractic documentation is being reviewed by multiple Medicare contractors and that we are failing these reviews miserably. So, where are we going wrong? In this and subsequent articles, let's address the top reasons we are failing review, starting with the No. 1 reason – our treatment plan documentation.

Chiropractic Use and Changes in Health Among Older Medicare Beneficiaries:
A Comparative Effectiveness Observational Study

J Manipulative Physiol Ther 2013 (Nov);   36 (9):   572-584

The evidence in this study suggests that chiropractic treatment has comparable effects on functional outcomes when compared with medical treatment for all Medicare beneficiaries, but increased risk for declines in self-rated health among beneficiaries with back conditions.

Trends in the Use and Cost of Chiropractic
Spinal Manipulation Under Medicare Part B

Spine J. 2013 (Nov);   13 (11):   1449–1454

The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.

Straight Chiropractic Philosophy As A Barrier To Medicare Compliance:
A Discussion of 5 Incongruent Issues

Journal of Chiropractic Humanities 2013 (Oct 24);   20 (1):   19–26

The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.

Beyond Spinal Manipulation: Should Medicare Expand Coverage
for Chiropractic Services? A Review and Commentary on the
Challenges for Policy Makers

Journal of Chiropractic Humanities 2013 (Aug 28);   20 (1):   9–18

The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.

Cross-Referencing Regions of Complaint, PART Findings,
Diagnoses and CPT Codes

Dynamic Chiropractic ~ June 15, 2013

In 2012 the Centers for Medicare and Medicaid Services and CMS-contracted reviewers performed chiropractic Medicare reviews nationwide. The results of their efforts were not good news for the chiropractic profession. Volumes have already been written about this concern. Here, I offer a set of questions to help guide doctors in documenting the number of patient complaints, subluxations, diagnoses, regions adjusted and the appropriate billing codes. This series of questions is accompanied by comments and tables to clarify the importance of each question.

The Medicare Hurdle That Continues to Block
Our Professional Progress

Dynamic Chiropractic ~ April 9, 2012

The rules for Medicare are spelled out in section 240 of chapter 15 of the Medicare Benefit Policy Manual [3] and in your local carrier's or administrator's Local Coverage Determination (LCD). The terminology is generally consistent; however, it can be confusing based on how the language is misinterpreted by chiropractors and those who teach documentation and coding seminars. Contrary to what many believe, Medicare documentation is not subluxation-based, even though parts of section 240 can mislead one in this direction. Why do we say this? Because "subluxation-based" to chiropractors is a different concept compared to subluxation-based to Medicare, and this fact is clearly spelled out in the rules.

Chiropractic Episodes and the Co-occurrence of Chiropractic and
Health Services Use Among Older Medicare Beneficiaries

J Manipulative Physiol Ther 2012 (Mar);   35 (3):   168-175 ~ FULL TEXT

Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

A Longitudinal Study of Chiropractic Use Among Older Adults
in the United States

Chiropractic & Osteopathy 2010 (Dec 21);   18:   34 ~ FULL TEXT

There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".

Best Practices Recommendations for Chiropractic Care for Older Adults:
Results of a Consensus Process

J Manipulative Physiol Ther 2010 (Jul);   33 (6):   464-473 ~ FULL TEXT

A multidisciplinary panel of experienced chiropractors was able to reach a high level (80%) of consensus on evidence-informed best practices for the chiropractic approach to evaluation, management, and manual treatment for older adult patients.

Trends, Major Medical Complications, and Charges Associated with Surgery
for Lumbar Spinal Stenosis in Older Adults

JAMA. 2010 (Apr 7);   303 (13):   1259–1265 ~ FULL TEXT

There is a lack of evidence-based support for the efficacy of complex fusion surgeries over conservative surgical decompression for elderly stenosis patients. There is, however, a significant financial incentive to both hospitals and surgeons to perform the complex fusions. Spinal stenosis is the most frequent cause for spinal surgery in the elderly. There has been a slight decrease in these surgeries between 2002 and 2007. However, there has also been an overall 15 fold increase in the more complex spinal fusions (360 degree spine fusions).

Correctly Completing a Medicare Claim
Dynamic Chiropractic ~ June 3, 2009

This article takes a step-by-step analysis on what goes in each box on the HCFA form, and reviews the proper use of modifiers.

American Chiropractic Association Responds to the May 2009 OIG Report
ACA News ~ June 10, 2009

In a response released today, the American Chiropractic Association (ACA) refuted the findings and recommendations outlined in a May 2009 report released by the Department of Health and Human Services Office of the Inspector General (OIG), noting the methods used by the OIG may have resulted in an overestimate of inappropriate claims. In commenting on the report, ACA said the OIG’s decision to restrict data collection to only those episodes of chiropractic care resulting in claims of more than 12 visits by the same doctor, likely skewed the data pool by focusing on a subpopulation previously identified to be more problematic. As a point of comparison, an OIG report released in 2005 investigated data collected from a global sample of claims.
Review OIG's 2009 Full Report or the 2005 Full Report now.

Patients in Medicare Demonstration Project
Give Their Chiropractors High Marks

ACA News ~ January 26, 2010

According to long-awaited results from a congressionally mandated pilot project testing the feasibility of expanding chiropractic services in the Medicare program, patients have a high rate of satisfaction with the care they receive from doctors of chiropractic. When asked to rate their satisfaction on a 10-point scale, 87 percent of patients in the study gave their doctor of chiropractic a level of 8 or higher. What’s more, 56 percent of those patients rated their chiropractor with a perfect 10.

Medicare Do's and Don'ts
A step-by-step approach to use of modifiers, and HCFA requirements. This 2 page Acrobat document (93 KB) covers all the most recent information updates amd recommendations. Thanks to the ACA and Susan McClelland for preparing these materials!

President Bush Signs Legislation Reversing Medicare Physician Fee Cuts
Arlington, Va. - Feb. 8, 2006
  President Bush has signed legislation that not only reverses the current 4.4 percent Medicare physician payment reduction, which went into effect on the first of year, but will also provide automatic reprocessing of claims retroactive to Jan. 1, 2006. The legislation was included in the Deficit Reduction Act.
 
   

Medicare LINKS
 
   

Centers for Medicare & Medicaid Services (CMS)
This index page links you to information on the Medicare program. Each link represents a topic. Topic links are grouped by category. Each topic contains from 1 to 20 pages of information. The first page of each topic starts with an Overview. At the bottom of every page, downloads and lists of related links offer you more information.

Medicare's Documentation Guidelines for E&M Services
Currently, (as of November 2005) carriers are to continue reviews using both the 1995 and 1997 Documentation Guidelines for E&M Services (whichever is more advantageous to the physician) until further notice.

 
   

The Medicare Demonstration Project
 
   

MedLearn Matters:
The Chiropractic Expansion Project

Medicare April 4, 2005

This 20-page Adobe Acrobat file (412 KB) gives you CPT and DX codes that Medicare is going to pay for, and also lists zip codes that are going to be in the project areas. Really alot of information here.

Introduction and Billing Recommendations
Chiropractic Economics March 2005

Chiropractors who are located in any of the four demonstration project areas identified by the Centers for Medicare and Medicaid Services (CMS) will have the opportunity to prove to Congress that chiropractic care is feasible, advisable and beneficial for Medicare recipients.

Medicare Revises Requirements For Chiropractic Billing
Center for Medicare and Medicaid ~ FULL TEXT

The Center for Medicare and Medicaid Services (CMS) has issued revised requirements for chiropractic billing of active/corrective treatment and maintenance therapy. As of 10-01-2004 every chiropractic claim (those containing HCPCS code 98940, 98941, 98942) should include the Acute Treatment modifier (AT) if active/corrective treatment is being performed.

Congress Approves Plan to Test Expanded Medicare Access to DCs
www.acatoday.com

The current Medicare program imposes an arbitrary limit on the covered services that can be offered by America's 60,000 doctors of chiropractic and sought by millions of older chiropractic patients. Under current law, a chiropractor may only provide Medicare beneficiaries with a single covered service (manual manipulation of the spine to correct a subluxation) despite the fact that they are licensed in all 50 states to provide additional services that are currently covered under Medicare, including x-rays and other diagnostic tests and physiotherapy services. The ACA has long contended that Medicare's arbitrary limit on chiropractic services is harmful to patients and costly to taxpayers. The four-site, two-year demonstration, will likely have a profound impact in rural and medically underserved areas where beneficiaries will no longer be forced to visit a second or third provider to receive the full range of necessary services.

ACA's Demo Page
As part of legislation overhauling the 38-year old Medicare program -- passed by the House of Representatives on November 22nd and the Senate on November 24th, 2004 - President Bush authorized a two-year pilot project designed to test expanded access to chiropractic services for America's seniors.

Illinois Demonstration Project LCD
Illinois Medicare has provided an Adobe Acrobat outline of how to describe the subluxation, PART documentation, and the complete documentation requirements for Initial Exams, and subsequent visits. It also defines "necessity for treatment", what is Maintenance care, proper ICD-9 coding for the subluxation, and the codes that support "medical necessity", broken into short, medium and long duration. This document is clear, short (12 pages), and invaluable. You can locate the LCD (Local Coverage Determination) for your demonstration area here: Illinois,   Iowa,   Virginia,   and New Mexico.

The Chiropractor's Guide
Compiled by Lisa Paoli, CMRS of MedOffice Solutions

This 8-page document (also available as a Word document ~ 72 KB) covers proper coding recomendations specifically for Illinois providers. Thanks Lisa! Updated on 6-11-2005

Medicare's Chiropractic Demonstration Project
Federal Register: Jan. 28, 2005; 70 (18): 4130–4132 ~ FULL TEXT

Read the details of the Medicare Chiropractic Demonstration Project, which will test expanded access to chiropractic services for America's senior citizens in a two-year, four-site demonstration project starting April 2005. Review this document for locations and the expanded services chiropractors will be able to provide.

Medicare's Primary Recommendations For HCFA Filing
  • AT modifier - The AT modifier should be used for every service on all demonstration claims where active/corrective treatment is provided.

  • DEMO 45 - Demo 45 must be indicated in block 19 of the CMS 1500 claim form for all demonstration claims. For electronic submissions, it would be REF02 (REF01=P4) in the 2300 loop.

  • Separate Demonstration services (Physical Therapy) from spinal CMT - All claims for demonstration services should be submitted on a separate claim form from claims from spinal CMT (98940, 98941, 98942).

  • GP modifier - The GP modifier should be used for all therapy services.

  • 25 modifier - When manipulation and E&M codes are billed on the same visit, it is necessary to attach a 25 modifier to the E/M code.

  • Local Coverage Determinations (LCDs) - Chiropractors must follow local coverage determinations for therapy and other demonstration services—this is particularly important for therapy services. They must also ensure that appropriate diagnosis codes are used for each procedure. Information regarding LCDs can be found on your carrier websites.


Medicare Modifiers
MODIFIER      USAGE
AT

The Acute Treatment (AT) modifier must be attached to the spinal manipulative CPT codes (98940, 98941, or 98942) to distinguish it from unpaid maintenance visits.

GP

Identifies the service as "Physical Therapy". In Illinois I have have been advised that all PT codes must be submitted with BOTH the AT (acute treatment) AND GP modifiers attached like this: Code - ATGP. In non-demonstration areas, GP, coupled with the GY modifier, tells Medicare you know that this is a non-covered therapy.

GY

This indicates to Medicare that you know that this is a non-covered service (like Physical Therapy services outside of the Demonstration Project areas).

GA

This indicates that Medicare will deny a covered service as not reasonable and necessary, and that the provider has an ABN signed by the beneficiary.

GZ

This indicates that Medicare will deny a covered service as not reasonable and necessary, and that the provider does NOT have an ABN signed by the beneficiary.


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