CHIROPRACTORS GUIDE FOR EXPANSION OF COVERAGE FOR CHIROPRACTIC SERVICES
 
   

Expansion of Coverage for
Chiropractic Services Demonstration (MMA)

Available as a Word Document
 
   

Billing rules from this whole article are summed up here: (updated 5-21-2005)

(These rules are for Illinois, although it "should" be the same for all the demo sites:


  1. Billing for the CMT (98940-42) will be the same rules as before the project (that is, the CMT codes must have the -AT modifier (active therapy), or it will be rejected as "maintenance care")



  2. Billing Demonstration project codes – you must put them on a separate claim form and you must use the diagnosis codes listed in this article. So when you are billing for demo codes PLUS CMT you will use 2 different claim forms.



  3. You must put "demo 45" in box 19 of a CMS1500 form or in the ASCX12837 electronic format, you should report the demonstration number in the 2300/REF loop. In addition to demo 45, you MUST have the date last seen (or assessed) and UPIN of attending physician. So Box 19 must be "demo 45 xx/xx/xxxx U12345" but with dates and correct UPIN of coarse. PLEASE DO NOT MAKE THE MISTAKE, a UPIN is different then a PIN. Put the UPIN in Box 19.



  4. Box 17 - Must have referring doctors name or if there is no referring, put attending/ordering doctors name



  5. Box 17A - Must have UPIN of referring/attending doctor



  6. You must use AT modifier on ALL codes that are active treatment and not maintenance care.



  7. You must put an AT & GP modifier on all Physical therapy codes (excluding 64550)



  8. You must put an AT & 25 modifier on all E & M codes (office visits)



  9. You must put an AT modifier on the CMT codes



  10. Have a new plan of care every 30 days (following the re-exam)



  11. Change Box 14’s dates according to description below from the CMS guidelines (see page 3)



  12. Make sure your documentation is in order to back up all the procedures you do, everything has to be documented or it wasn’t done.



The Use of CPT Modifiers:

AT = Active Therapy

GP = Identifies it as a Physical Therapy (PT) covered under the demonstration project

GY= a non-covered service. If you supply PT to a patient in a non-demonstration project area, you still want Medicare to know that chiropractors provide this type of service. You must also signify that the patient knows Medicare won't be paying for it with the GY modifier.

GA = is a REQUIRED modifier that MUST be used whenever you have an ABN signed

GZ = is an optional, although strongly recommended, modifier that signifies
you know you should have had an ABN signed but, for some reason, did not.

-25 = Significant, separately identifiable E&M service, provided by the same physician on the same day as another procedure which also contains a pre- and post-treatment assessment.

-51 = Multiple Procedures modifier

-52 = Reduced Services Modifier

-59 = Distinct Procedural Service This advises that the second service was distinct or separate from other services performed on the same day.

 

Provider Types Affected

Chiropractors who practice in the States of Maine and New Mexico, Scott County, Iowa, 26 counties in Illinois (including Cook, DeKalb, DuPage, Grundy, Kane, Kendall, McHenry, Will, Boone, Bureau, Carroll, Henry, JoDaviess, Kankakee, Lake, LaSalle, Lee, Marshall, Mercer, Ogle, Putnam, Rock Island, Stark, Stephenson, Whiteside, and Winnebago counties), and 17 counties in central Virginia (including Pittsylvania, Campbell, Appomattox, Nelson, Buckingham, Fluvanna, Louisa, Caroline, Hanover, New Kent, Henrico, Richmond City, Danville City, Goochland, Cumberland, Powhatan, and Amelia counties).

Provider Action Needed

Under a two-year demonstration project beginning April 1, 2005, doctors of chiropractic will be able to bill Medicare carriers for the Part B medical, radiology, clinical lab, and therapy services that they provide for their Medicare fee-for-service patients. These services must be billed separately from current services that are covered under Medicare. You must include a demonstration code for all demonstration claims.

Under this demonstration, doctors of chiropractic will also be allowed to bill Medicare for CPT code 98943—extraspinal manipulation. The fee amounts for 98943 per geographic area can be found in Table 1 of this article. Coverage will also be expanded to include other ancillary services chiropractors are legally allowed to provide and Medicare currently covers. These procedures include electrotherapy, ultrasound, TENS therapy, and other services that are medically necessary for the treatment of neuromusculoskeletal conditions. Chiropractors will be allowed to provide physical therapy services and to refer patients for therapy under this demonstration.

Chiropractors will also be reimbursed for Evaluation and Management (E&M) services delivered for neuromusculoskeletal conditions. Under the demonstration, chiropractors will be allowed to bill Medicare for both an E&M visit and for treatment the first time you assess a patient, as well as for current patients in instances such as when there is a new condition, exacerbation or recurrence of the current condition, or for a reassessment midway through treatment.

Chiropractors should not bill for an E&M service every time they treat a patient. Chiropractors billing Medicare under this demonstration must follow the same documentation guidelines that physicians follow for E&M services.

For example, chiropractic manipulation codes include a brief pre-manipulation patient assessment. Additional E&M services may be reported separately using the modifier "-25" if, and only if, the patient’s condition requires a significant separately identifiable E&M service. When manipulation and E&M codes are billed for the same visit, it is necessary to attach a "-25" modifier to the E&M code. These guidelines can be found at:

http://www.cms.hhs.gov/medlearn/emdoc.asp

Additional E&M guidance can also be found in the Medicare Claims Processing Manual, publication 100- 04, Chapter 12, Section 30. This manual may be accessed at:

http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

 

Services provided under this demonstration must be related to acute or active treatment, not maintenance or prevention of neuromusculoskeletal conditions. You must place an AT modifier next to every CPT code on all claims when providing active/corrective treatment to treat acute or chronic subluxation.

You should be aware that while under this demonstration, chiropractors will be subject to the same coverage and payment rules that physicians and physical therapists must follow, such as:

  1. rules that apply to physicians regarding billing for the delivery of E&M services and treatment in the same visit;

2) coinsurance or deductible rules; and 3) rules regarding the delivery of physical therapy services, including identifying these services using the GP modifier, and certifying the plan of care every 30 days. These requirements can be found in the Medicare Benefit Policy Manual 100-2 in Chapter 15, Sections 220 and 230 and the Medicare Claims Processing Manual 100-4 in Chapter 5, Section 20 and other manual sections.

 

The Medicare Benefit Policy Manual may be found at:

http://www.cms.hhs.gov/manuals/102_policy/bp102index.asp

In addition, chiropractors must follow physician rules for providing therapy services under the "incident to" provision of the physician regulation. When a physical therapy service is provided incident to the service of a chiropractor, the person who furnishes the service must meet the standards and conditions that apply to physical therapists, except that a license is not required.

This means that unless chiropractic students, chiropractic assistants, or sports trainers have graduated from a physical therapy curriculum approved by:

1) the American Physical Therapy Association, or 2) The Committee on Allied Health Education and Accreditation of the American Medical Association, or 3) the Council on Medical Education of the American Medical Association and the American Physical Therapy Association, they cannot provide therapy services incident to a chiropractor. The only exception is that certain persons trained prior to January 1, 1966 may be grandfathered (see 42 CFR 484.4).

Finally, you should check your local Medicare carrier website for information on local coverage decisions regarding demonstration services.

 

Rules from this whole article summed up:

  1. Billing for the CMT (98940-42) will be the same rules as before the project

  2. Billing Demonstration project codes – you must put them on a separate claim form and you must use the diagnosis codes listed in this article. So when you are billing for demo codes PLUS CMT you will use 2 different claim forms

  3. You must put "demo 45" in box 19 of a CMS1500 form or in the ASCX12837 electronic format, you should report the demonstration number in the 2300/REF loop

  4. You must use AT modifier on ALL codes that are active treatment and not maintenance care.

  5. You must put an AT & GP modifier on all Physical therapy codes (excluding 64550)

  6. You must put an AT & 25 modifier on all E & M codes (office visits)

  7. You must put an AT modifier on the CMT codes

  8. Have a new plan of care every 30 days

  9. Change Box 14’s dates according to description below from the CMS guidelines

  10. Make sure your documentation is in order to back up all the procedures you do, everything has to be documented or it wasn’t done.

 

Box 14:

Enter either an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) date of current illness, injury, or pregnancy.  For chiropractic services, enter an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) date of the initiation of the course of treatment.  

Therefore if a patient comes in with a neck injury on Monday June 2, 1999 you will put 06/02/1999 in box 14, BUT then if she comes back on June 5th, 1999 with a lower back pain, you would change the date in box 14 to 06/05/1999.

 

 

CPT codes that are covered under the demonstration project:

Code
Chiropractic Manipulation Codes

98940 manipulation 1-2 regions

98941 manipulation 3-4 regions

98942 manipulation 5 regions

98943 New for demo--extraspinal manipulation

 

Code
Evaluation and Management Codes

99201 New patient 10 minutes

99202 New patient 20 minutes

99203 New patient 30 minutes

99204 New patient 45 minutes

99205 New patient 60 minutes

99211 Established patient 5 minutes

99212 Established patient 10 minutes

99213 Established patient 15 minutes

99214 Established patient 25 minutes

99215 Established patient 40 minutes

 

Code
Diagnostic Codes

95831 Muscle testing, manual with report; extremity or trunk

95832 Hand, with or without comparison with normal side

95833 Total evaluation of body, excluding hands

95834 Total evaluation of body, including hands

95851 Range of motion measurements and report; each extremity or each trunk section

95852 Hand, with or without comparison with normal side

95857 Tensilon test for myasthenia gravis

95858 With electromyographic recording

95860 Needle electromyography; one extremity with or without related paraspinal areas

95861 Two extremities with or without related paraspinal areas

95863 Three extremities with or without related paraspinal areas

95864 Four extremities with or without related paraspinal areas

95867 Cranial nerve supplied muscles, unilateral

95868 Cranial nerve supplied muscles, bilateral

95900 Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study

95903 Motor, with F-wave study

95904 Sensory

 

Code
Therapy Codes

64550 Application of surface (transcutaneous) neurostimulator

97012 traction, mechanical

97018 paraffin bath

97020 Microwave

97024 Diathermy

97026 Infrared

97028 Ultraviolet

97032 electrical stimulation, constant attendance

97034 contrast baths

97035 Ultrasound

97039 unlisted modality

97110 therapeutic exercise

97112 neuromuscular reducation

97113 aquatic therapy with exercise

97116 gait training

97124 Massage

97139 unlisted therapeutic procedure

97140 Manual therapy techniques

97150 therapeutic procedures, group

97504 orthotic fitting and training

97530 Therapeutic activities--dynamic activities to improve functional performance

97703 check out for orthotics and prosthetic use

97750 physical performance test or measurement, with written report

97799 unlisted physical medicine/rehabilitation service

G0283 unattended electrical stimulation for other than wound care

 

Code X rays

72010 x-ray spine entire

72020 x-ray spine, 1 view

72040 xray spine cervical 2-3 views

72050 x-ray, spine cervical 4+ views

72052 x-ray spine cervical complete,

72069 x-ray spine standing for thoracolumbar

72070 x-ray spine thoracic 2 views

72072 x-ray spine thoracic 3 views

72074 x-ray, spine thoracic 4+ views

72080 x-ray spine thoracolumbar 2 views

72090 x-ray spine thoracolumbar supine and standing

72100 x-ray spine lumbosacral 2-3 views

72110 x-ray spine lumbosacral 4+ views

72114 x-ray spine lumbosacral complete

72120 x-ray spine lumbosacral bending only

72170 x-ray pelvis, 1-2 views

72190 x-ray pelvis complete

72200 x-ray sacroiliac joints, up to 3 views

72202 x-sacroiliac joints 3+ views

72220 x-ray sacrum and coccyx 2+ views

73000 x-ray clavicle complete

73010 x-ray scapula compete

73020 x-ray shoulder 1 view

73030 x-ray shoulder 2+ views

73050 x-ray acromioclavicular joint, bilateral

73060 x-ray humerus, 2+ views

73070 x-ray elbow 2 views

73080 x-ray elbow 3+ views

73090 x-ray forearm 2 views

73100 x-ray wrist, 2 views

73110 x-ray wrist, 3+ views

73120 x-ray hand 2 views

73130 x-ray hand 3+ views

73140 x-ray finger(s) 2+ views

73500 x-ray hip unilateral 1 view

73510 x-ray hip unilateral 2+ views

73520 x-ray hip bilateral 2+ views

73550 x-ray femur 2 views

73560 x-ray knee 1-2 views

73562 x-ray knee 3 views

73564 x-ray knee 4+ views

73565 x-ray bilateral knees standing

73590 x-ray tibia fibula 2 views

73600 x-ray ankle 2 views

73610 x-ray ankle 3+ views

73620 x-ray foot, two views

73630 x-ray foot, 3+ views

73650 x-ray heel 2+ views

73660 x-ray toe--2 or more views

71100 x-ray ribs, unilateral; 2 views

71110 x-ray ribs, bilateral 3 views

71120 x-ray sternum, 2+ views

71130 x-ray, sternum+sc joint

 

Make sure to put a AT modifier on ALL codes that are NOT maintenance care.


Diagnosis codes used with the demonstration project codes listed above.

Do not use these codes when billing for CMTs.

Medicare Demonstration Project Cheat Sheet Code Description Specific Codes Within the Range

307 Special symptoms 307.81

138 Late effects of poliomyelitis

340 Multiple sclerosis

346 Migraine 346.0, 346.1, 346.2, 346.8, 346.9

350 Trigeminal neuralgia 350.1, 350.2

352 disorder cranial nerve 352.4

353 disorder, nerve root and plexus 353.0, 353.1, 353.2, 353.4, 353.6

354 Mononeuritis, upper limb and multiple 354.0, 354.1, 354.2, 354.3, 354.4, 354.8, 354.9

355 Mononeuritis, lower limb 355.0, 355.1, 355.2, 355.3, 355.4, 355.5, 355.6, 355.71, 355.79, 355.8, 355.9

356 Neuropathy, hereditary and idoiopathic 356.1, 356.4, 356.8, 356.9

358 disorders myoneural 358.00, 358.01

715 Arthritis, osteoarthritis* 715.0x, 715.1x, 715.2x, 715.3x, 715.8x, 715.9x

716 Arthropathies, NEC/NOS* 716.1x, 716.2x, 716.3x, 716.4x, 716.5x, 716.6x, 716.8x, 716.9x

717 derangement, knee internal 717.0-3, 717.40-43, 717.49, 717.5-7, 717.81-84, 717.85, 717.89, 717.9

718 derangement, other joint* 718.0x, 718.1x, 718.6x, 718.8x, 718.9x, 718.48

719 disorder, joint NEC/NOS* 719.0x, 719.1x, 719.2x, 719.3x, 719.4x, 719.5x, 719.6x, 719.7x, 719.8x, 719.9x

720 Spondylitis, ankylosing and othe 720.0, 720.1, 720.2, 720.81, 720.89, 720.9

inflammatory spondylopathies

721 Spondylosis and allied disorders 721.0, 721.1, 721.2, 721.3, 721.4, 721.5, 721.6, 721.7, 721.8, 721.90, 721.91

722 disorder, intervertebral disc 722.0, 722.10-.11, 722.2, 722.30-.32, 722.39-.4, 722.51-.52, 722.6 722.70-.73, 722.81-.83, 722.91-.93

723 disorder cervical spine 723.0, 723.1, 723.2, 723.3, 723.4, 723.5, 723.6,

723 disorder cervical spine 723.7, 723.8, 723.9

724 disorders, back NEC/NOS 724.00-03, 724.1-6, 724.70, 724.71, 724.79, 724.8, 724.9

725 Polymyalgia rheumatica

726 enthesopathies, peripheral and allied syndromes 726.0, 726.10-.12, .19, 726.2, 726.30-.32, .39, 726.4, .5, 726.60-.65, .69, 726.70-.73.79,

726.8, .90, .91

727 disorders, synovium tendon and bursa 727.00-.06, 727.09,.1, .2, .3, 727.40-.43, 727.49, 727.50-.51, 727.59,

727.60-.69, 727.81-.83, 727.89-.9

728 disorders, muscle, ligament and fascia 728.10-.12, 728.2, .3, .4, .5, .6, 728.71, 728.79, 728.81, 728.83, 728.85,

728.87, 728.89, 728.9

733 Other disorders of bone and cartilage 733.6, 733.92

735 deformity, toe acquired 735.0, 735.1, 735.2, 735.4, 735.5, 735.8, 735.9

736 Deformity, limbs acquired 736.00-.07, 736.09-.1, 736.20-.22, 736.29-.32, 736.39, 736.41-.42, 736.6,.70-.76, 736.79,

736.81, 736.89

737 Curvature spine 737.0, 737.10, 737.11, 737.12, 737.19, 737.20-22, 737.29, 737.30-34,

737.40-43, 737.8, 737.9

738 deformity, acquired 738.2-9

739 Lesions, nonallopathic NEC 739.0-9

754 Congenital musculoskeletal deformities 754.1, 754.2, 754.40-44, 754.50-53, 754.59, 754.60-62, 754.69, 754.70, 754.71, 754.79

756 other congenital musculoskeletal abnormalities 756.10-15, 756.17, 756.19, 756.2, 756.3, 756.4, 756.82, 756.83, 756.89

840 Sprains and strains of shoulder and upper arm 840.1-9

841 Sprains and strains of elbow and forearm 841.0-.3,

842 Sprains and strains of wrist and hand 842.00-02, 842.09-13, 842.19

843 Sprains and strains of hip and thigh 843.0, 843.1, 843.8, 843.9

844 Sprains and strains of knee and leg 844.0-844.3, 844.8, 844.9

845 Sprains and strains of ankle and foot 845.00-03, 845.09-13, 845.19

846 Sprains and strains of the sacroiliac region 846.0-3, 846.8, 846.9

847 Sprains and strains of back NEC/NOS 847.0-4, 847.9

848 Sprains and strains, ill-defined, NEC 848.3, 848.40-42, 848.49, 848.8, 848.9

905 Late effects, musculoskeletal and 905.1-9

connective tissues injuries

907 Late effects, injuries to the nervous system 907, 907.1-5, 907.9

922 Contusion, trunk 922.1, 922.31, 922.33, 922.33, 922.8

923 Contusion, upper limb 923.00-03, 923.09-11, 923.20-21, 923.3, 923.8, 923.9

924 Contusion, lower limb 924.00, 924.01, 924.10-11, 924.20-21, 924.3-5, 924.8, 924.9

955 Injury, peripheral nerve(s) of shoulder 955.0-9

girdle and upper limb

956 Injury, peripheral nerve(s) of pelvic 956.0-5, 956.8, 956.9

girdle and lower limb

958 Certain traumatic complications 958.6

784 Symptoms involving head and neck 784

* = "x" specifies anatomic site, and any value would be appropriate

 

  CMT DX CODES FOR MEDICARE
  ONLY USE THESE DX CODES ON CMT CODES (98940-42) ONLY
         


 SHORT TERM CARE



 MODERATE TERM CARE CONTINUED
307.81 Tension Headache

846.3 Sprain/Strain of sacrotuberus (ligament)
346.00. Classical migraine w/o intractable migrain

846.8 Sprain/Strain of sacrolic, other spec. sites
346.01 Classical migraine with intractable migrain

847.0. Sprain/Strain of neck
346.10. Common migraine w/o intractable migraine

847.1 Sprain/Strain of thoracic
346.11 Common migraine with intractable migraine

847.2 Sprain/Strain of lumbar
346.20. Variants of migraines w/o intract. migraine

847.3 Sprain/Strain of Sacrum
346.21 Variants of migraines with intract migraine

847.4 Sprain/Strain of Coccyx
346.80. Other forms of migraines w/o intract migrain





346.81 Other forms of migraines with intract migrain





346.90. Migraine, unspec w/o intractable migraine



 LONG TERM CARE
346.91 migraine, unspec with intractable migraine

721.7 Traumatic Spondylopathy
355.1 Meralgia paresthetica

722.0 Displmt of intervertebral disc w/o myelopathy
721.0. Cervical Spondylosis w/o myelopathy

722.10. Displmt of lumbar intervertebral w/o myelopa
721.2 Thoracic Spondylosis w/o myelopathy

722.11 Displmt of thoracic intervertebral w/o myelopa
721.3 Lumbosacral spondylosis w/o myelopathy

722.4 Degeneration of cervical intervertebral disc
721.90. Spondylosis of unspec. site w/o myelopathy

722.51 Degeneration of thoracolumbar intervert. disc
723.1 Cervicalgia

722.52 Degeneration of lumbosacral intervert. disc
724.1 Pain in the thoracic spine

722.81 Postlaminectomy syndrome cervical region
724.2 Lumbago

722.82 Postlaminectomy syndrome thoracic region
724.5 Backache unspecified

722.83 Postlaminectomy syndrome lumbar region
728.85 Muscle Spasm

723.0. spinal Stenosis in cervical region
784.0. Headache

724.01 Spinal Stenosis, thoracic region






724.02 Spinal Stenosis, lumbar region


 MODERATE TERM CARE

724.3 Sciatica
353.0. Brachial Plexus Lesions

756.12 Spondylolisthesis
353.1 Lumbosacral Plexus Lesions





353.2 Cervical Root Lesions





353.3 Thoracic Root Lesions

IN BOXES #1 & #3 YOU MUST USE THESE
353.4 Lumbosacral Root Lesions

FOR MEDICARE CLAIMS
353.8 Other nerve Root and Plexus Disorders



SUBLUXATION CODES 
355.0. Lesion of the sciatic Nerve

739.0. HEAD
355.2 Other Lesions of fermoral nerve

739.1 CERVICAL
355.8 Mononeuritis of Lower Limb Unspecified

739.2 THORACIC
719.48 Pain in joint (other spec. sites)(must specify site)

739.3 LUMBAR
720.1 Spinal Enthesopathy

739.4 SACRAL
722.91 Other & Unspec. disc disorder, cervical reg.

739.5 PELVIC
722.92 Other & Unspec. disc disorder, thoracic reg





722.93 Other & unspec. disc disorder, Lumbar reg





723.2 Cervicocranial Syndrome





723.3 Cericobrachial Syndrome





723.4 Brachial Neuritis or radiculitis





723.5 Torticollis unspecified





724.4 Thoracic or lumbosacral neuritis or radiculitis





724.6 Disorder of sacrum, ankylosis





724.79 Coccygodynia (disorder of coccyx)





724.8 Other Symptoms referable to back, facet syndr





729.1 Myalgia and myositis unspec





729.4 Fascitis unspec





738.4 Acquired spondylolisthesis





756.11 Spondylosis, lumbosacral reg





846.0. Sprain/Strain of lumbosacral (joint)(ligament)





846.1 Sprain/Strain of sacroiliac ligament





846.2 Sprain/strain of Sacrospinatus (ligament)





 

 This was quoted in the April 19th, 2005 WPS Seminar:

Budget Neutrality:

  • Legislation requires demonstration to be budget neutral

    • Aggregate Medicare provider payments may not exceed amount that would have been paid in absence of demonstration.

If demonstration is not found to be cost neutral (based on it’s estimated impact on Medicare Part A and Part B costs), CMS will RECOUP excess costs via payments made to all Medicare chiropractic service providers

  • CMS anticipates any necessary fee reduction to be made in the 2010 and 2011 fee schedules

  • If CMS determines that the adjustment would exceed 2% of chiropractor fee schedule, it will implement the adjustment over a 2 year period

Detailed analysis of budget neutrality and proposed offset will be published in the 2009 Federal Register publication of physician fee schedule.

 

For more information on Medicare billing go to:

Tables: Fee Schedule Amounts, Zip Codes, Procedure Codes, and Diagnosis Codes

To access the tables referenced in this article, please see the article at:

http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0514.pdf

Chiropractic Book Guide from Medicare:

http://www.wpsic.com/medicare/provider/pdfs/chiro_care_book.pdf

This is posted for informational purpose, this is quoted straight from the Medicare April Communique Archives listed at http://www.wpsic.com/medicare/provider/provhome.shtml

These rules apply when billing Medicare in Demonstration areas listed in the first paragraph. If you are NOT in the Demonstration Project, Medicare will only pay for the CMT (98940-42) for active care.


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