HealthNow UMD
Article -- Coding Guidelines

Contractor Name
HealthNow

Contractor Number
00801

Contractor Type
Carrier

Article Database ID Number
A36087

Contractor Determination Number
CH001E02

Article Type
Article

Article Title
Chiropractic Services-2

Is the AMA CPT / ADA CDT Copyright Statement Required?
Yes

CPT codes, descriptions, and other data only are copyright 2007 American Medical Association (or such other data of publication of CPT). All Rights Reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. (C) 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction
Upstate New York

Original Article Effective Date
08/19/2005

Article Revision Effective Date
For services performed on or after 06/04/2007

Article Ending Effective Date

Coding Guidelines

   1.  The guidelines of the Correct Coding Initiative (CCI) supersede all
       coding instructions in this LCD.

   2.  The diagnosis code(s) must best describe the patient's condition for
       which the service was performed.

   3.  Billed services for which the provider expects a medical necessity
       denial should have either the GA (with signed ABN) or GZ (without
       signed ABN) modifier attached to the code. If the service is
       statutorily non-covered or without benefit category, use the GY
       modifier instead.

   4.  Two diagnoses are required on all claims, and on claims for patients
       whose condition is exacerbated, a third diagnosis is also required.
       The precise level of the subluxation must be listed as the primary
       diagnosis, while the resulting disorders are to be listed as the
       secondary diagnosis. For exacerbated conditions, report ICD-9-CM code
       V58.9.

   5.  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.

   6.  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.

   7.  Diagnostic x-rays, evaluation and management services and physical
       therapy are not covered when performed by chiropractors. When
       submitted for a denial for the purposes of secondary coverage, these
       services may be coded utilizing a "GY" modifier so that proper denials
       will be shown on the Explanation of Medicare Benefits form.

   8.  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
       UPIN number in Item 17a, or NPI (when effective) in Item 17b, of the
       CMS-1500 form, or the electronic equivalent, as the ordering
       physician.

   9.  Effective for dates of service on or after October 1, 2004, modifier
       AT (acute treatment) must be reported for all claims for
       active/corrective treatment.

   10. Claims for maintenance therapy must be submitted without modifer AT.

       If the chiropractic physician believes that manipulation services may
       be considered not to be reasonable and necessary, i.e., has exceeded
       the frequency limits established for that service, he/she may have the
       beneficiary sign a waiver of liability statement prior to providing
       the service. The waiver must indicate the specific reason why the
       chiropractor believes Medicare may not reimburse the service. The
       service should be submitted with a GA modifier, indicating that a
       waiver has been obtained, and include a copy of the waiver if
       submitting a paper claim.

   11. The GA modifier is informational only and does not trigger an
       automatic denial, i.e., the service could be paid by Medicare.
       Therefore, the provider should wait for the claim to be processed
       before billing the beneficiary for a denied service subject to the
       waiver of liability. If the provider has not obtained a waiver of
       liability from the beneficiary, modifier GZ should be reported with
       the claim.

   12. Chiropractic services may be performed in the office (11), home (12),
       assisted living facility (13), group home (14), inpatient hospital
       (21), outpatient hospital (22), emergency room (23), nursing facility
       for patients in a Part A stay (31), nursing facility for patients no
       longer in a Part A stay (32), custodial care facility (33),
       independent clinic (49), comprehensive outpatient rehabilitation
       facility (62), and state or local public health clinic (71).

CPT/HCPCS Codes

    98940           Chiropractic manipulative treatment (CMT); spinal,
                    one to two regions

    98941           ;spinal, three to four regions

    98942           ;spinal, five regions

    *98943;         extraspinal, one or more regions

Other Comments

   1.  For services that exceed the accepted standard of medical practice and
       may be deemed not medically necessary, the provider/supplier should
       provide the patient with an acceptable advance notice of Medicare's
       possible denial of payment.  An advance beneficiary notice (ABN)
       should be signed when a provider/supplier does not want to accept
       financial responsibility for the service.

   2.  This LCD was developed/revised as a joint document for New York and
       New Jersey.

   3.  Manual devices (those devices that are hand-held with the thrust of
       the force of the device being controlled manually) may be used by the
       chiropractor in performing manual manipulation of the spine. However,
       no additional payment is allowed for the use of the device or for the
       device itself.

   4.  No other diagnostic or therapeutic service furnished by a chiropractor
       or under his or her 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.

   5.  The following are examples (not an all inclusive list) of services
       that, when performed or ordered by the chiropractor, are excluded from
       Medicare coverage and for which the beneficiary is responsible for
       payment:

       -    Therapy for a chronic condition that does not meet the definition
            as described in the "Indications and Limitations" section of this
            LCD

       -    Maintenance therapy

       -    Laboratory tests

       -    X-rays/MRI/CT Scans

       -    Evaluation and management services

       -    Physiotherapy

       -    Traction

       -    Supplies

       -    Injections

       -    Drugs

       -    EKGs or any diagnostic study

       -    Acupuncture

       -    Orthopedic devices

       -    Nutritional supplements/counseling

       -    Any service ordered by the chiropractor

       -    Any manipulation where there exists one of the absolute
            contraindications

       -    Mechanical or electric equipment that is used for manipulations
            and does not meet the definition of "manual device" as specified
            in the "Description" section of this policy

       -    Any manipulation where the x-ray (or existing MRI or CT scan) or
            examination does not support one of the primary diagnoses listed
            in the "ICD-9-CM Diagnoses That Support Medical Necessity"
            section of this LCD.

   6.  A radiologist (or another authorized ordering practitioner) may accept
       a referral for an x-ray by doctors of chiropractic. The chiropractor
       may not order the x-ray.

   7.  Program Exclusions:

       Treatment of certain conditions may be excluded from coverage if it
       falls outside the scope of a chiropractor's practice as defined by
       State Law.

       Some chiropractors have been identified as using an "intensive care"
       concept of treatment. Under this approach, multiple daily visits (as
       many as four or five in a single day) are given in the office or
       clinic and so-called room or ward fees are charged, since the patient
       is confined to bed usually for the day. The room or ward fees are not
       covered.

Revision #1: Coding Guidelines and Other Comments sections updated along with LCD revision

Separate coding guideline document was created on 11/29/2005. Effective for claims submitted on or after 10/01/2003, independent clinic was added to coding guideline number 9.

Does this Article contain a "Least Costly Alternative" provision?
No