CPT CODES – 98940, 98941, 98943, 98942 – Chiropractic billing with AT modifer (2022)

procedure code and description

98940– Chiropractic manipulative treatment (CMT); spinal, one or two regions. Documentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT).– average fee payment-$20 – $30

98941-Chiropractic manipulative treatment (CMT); spinal, three or four regions.

Documentation must support that manipulative treatment occurred in three or four regions of the spine (region as defined by CPT) and one of the following: validated diagnoses for three or four spinal regions or validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings. – average fee payment- $40 – $50

98942 Chiropractic manipulative treatment (CMT); spinal, five regions. Documentation must support that manipulative treatment occurred in five regions of the spine (region as defined by CPT) and one of the following: validated diagnoses for five spinal regions or validated diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings validated diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings.

98943 Chiro, manipulation, extraspinal, one or more regions

Key Billing Requirements

In addition to other billing requirements explained in Medicare’s Manuals, it is important that you include the following information on the claim:

• The primary diagnosis of subluxation;

• The initial visit or the date of exacerbation of the existing condition;

• The appropriate Current Procedural Terminology (CPT) code that best describes the service:

o 98940: Chiropractic Manipulative Treatment (CMT); spinal, one or two regions;

o 98941: Spinal, three to four regions;

o 98942: Spinal, five regions.


NOTE: 98943: CMT, extraspinal, one or more regions, is not covered by Medicare.

• The appropriate modifier that describes the services:

o AT modifier* used on a claim when providing active/corrective treatment to treat acute or chronic subluxation;

o GA modifier used to indicate that you expect Medicare to deny a service (e.g., maintenance services) as not reasonable and necessary and that you have on file an Advance Beneficiary Notice (ABN) signed by the beneficiary; or

o GZ modifier used to indicate that you expect that Medicare will deny an item or service as not reasonable and necessary and that you have not had an ABN signed by the beneficiary, as appropriate.

NOTE: You must use the Acute Treatment modifier “AT” to identify services that are active/corrective treatment of acute or chronic subluxation and must document services in accordance with the Centers for Medicare & Medicaid Services’ (CMS) “Medicare Benefit Policy Manual”, Chapter 15, Section 240, when submitting claims.

Are we required to submit a claim to Palmetto GBA for maintenance therapy?

Answer:
Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

Medicare recommends that you consider providing the Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary. The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The beneficiary can then make a reasonable and informed decision about receiving and paying for the service.

On the ABN, if the beneficiary selects option one, she/he is agreeing to pay out of pocket for the service in question and requests that the chiropractor file a claim for that service with Medicare. With option one selected, the beneficiary retains appeals rights if he/she disagrees with Medicare’s claim decision. The chiropractor is permitted to ask for payment from the beneficiary.

If a beneficiary selects option two when he/she agrees to pay out of pocket for the service in question and does not want a claim sent to Medicare. In accordance with the ABN, the provider would not file a claim, and the beneficiary would not have appeal rights since no claim is being submitted. (Please note that the patient can change his/her mind at a future time and request the claim be submitted.)

If a beneficiary selects option three he/she chooses not to receive and pay for the service. No service is rendered, and no claim is filed. Since no claim is filed, the patient cannot appeal to Medicare for a payment decision.

Can a chiropractor use a manual device to assist with manipulation?

Answer:
Manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

Coverage Indications, Limitations, and/or Medical Necessity

Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

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.

Manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation. However, an x-ray may be used for this purpose if the chiropractor so chooses.

The word “correction” may be used in lieu of “treatment.” Also, a number of different terms composed of the following words may be used to describe manual manipulation as defined above:

– Spine or spinal adjustment by manual means;
– Spine or spinal manipulation;
– Manual adjustment; and
– Vertebral manipulation or adjustment.

In any case in which the term(s) used to describe the service performed suggests that it may not have been treatment by means of manual manipulation, the carrier analyst refers the claim for professional review and interpretation.

Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.

A subluxation may be demonstrated by an x-ray or by physical examination, as described below.

1. Demonstrated by X-Ray

An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.

2. Demonstrated by Physical Examination

Evaluation of musculoskeletal/nervous system to identify:
– Pain/tenderness evaluated in terms of location, quality, and intensity;
– Asymmetry/misalignment identified on a sectional or segmental level;
– Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
– Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under “physical examination” are required, one of which must be asymmetry/misalignment or range of motion abnormality.

The history recorded in the patient record should include the following:
– Symptoms causing patient to seek treatment;
– Family history if relevant;
– Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
– Mechanism of trauma;
– Quality and character of symptoms/problem;
– Onset, duration, intensity, frequency, location and radiation of symptoms;
– Aggravating or relieving factors; and
– Prior interventions, treatments, medications, secondary complaints.

A – Documentation Requirements: Initial Visit

The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. History as stated above.

2. Description of the present illness including:

– Mechanism of trauma;
– Quality and character of symptoms/problem;
– Onset, duration, intensity, frequency, location, and radiation of symptoms;
– Aggravating or relieving factors;
– Prior interventions, treatments, medications, secondary complaints; and
– Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo),bone (osseo or osteo), rib (costo or costal) and joint (arthro)and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

3. Evaluation of musculoskeletal/nervous system through physical examination.

4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.

(Video) Sam's Chiropractic Corner- CMT 98940, 98941, 98942, & 98943 Ratio

5. Treatment Plan: The treatment plan should include the following:

– Recommended level of care (duration and frequency of visits);
– Specific treatment goals; and
– Objective measures to evaluate treatment effectiveness.

6. Date of the initial treatment.

B – Documentation Requirements: Subsequent Visits

The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. History
– Review of chief complaint;
– Changes since last visit;
– System review if relevant.

2. Physical exam
– Exam of area of spine involved in diagnosis;
– Assessment of change in patient condition since last visit;
– Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services renderedmust 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 demonstrated by x-ray or physical exam as described above.

Most spinal joint problems may be categorized as follows:

1. Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression,of the patient’s condition.

2. Chronic subluxation: A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as in the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. (Medicare Benefit Policy Manual 100-2, 15, 240.1.3)

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.

3. Maintenance therapy: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. 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. Chiropractors who give or receive from beneficiaries an ABN shall follow the instructions in Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, section 20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.

Maintenance therapy is not a covered benefit.

4. Exacerbations: An exacerbation is a temporary marked deterioration of the patient’s condition due to flare-up of the condition being treated. This must be documented on the claim form and must be documented in the patient’s clinical record, including the date of occurrence, nature of the onset or other pertinent factors that will support the reasonableness and necessity of treatments for this condition.

5. Recurrence: A recurrence is a return of symptoms of a previously treated condition that has been quiescent for 30 or more days. This may require the reinstitution of therapy.

6. Contraindications: Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement.

A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. The following are relative contraindications to dynamic thrust:

? Articular hypermobility and circumstances where the stability of the joint is uncertain;
?Severe demineralization of bone;
? Benign bone tumors (spine);
? Bleeding disorders and anticoagulant therapy; and
? Radiculopathy with progressive neurological signs.

Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:

? Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
? Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
? An unstable odontoideum;
? Malignancies that involve the vertebral column;
? Infection of bones or joints of the vertebral column;
? Signs and symptoms of myelopathy or cauda equina syndrome;
? For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and
? A significant major artery aneurysm near the proposed manipulation.

Location of Subluxation:

The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified:

Area of Spine – Names of Vertebrae – Number of Vertebrae – Short Form or Other Name

Neck – Occiput (Occ, CO), Cervical (C1 thru C7), Atlas (C1), Axis (C2) – 7

Back – Dorsal (D1 thru D12) or Thoracic (T1 thru T12) or Costovertebral (R1 thru R12) or Costotransverse (R1 thru R12) – 12

Low Back – Lumbar (L1 thru L5) – 5

Pelvis – Iiii, r and l (I, Si)

Sacral – Sacrum, Coccyx, S, SC

In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment.

There are two ways in which the level of the subluxation may be specified.
– The exact bones may be listed, for example: C5, C6, etc.
– The area may suffice if it implies only certain bones such as: Occipito-atlantal (occiput and C1 (atlas)), lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).

Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:
– Off-centered
– Misalignment
– Malpositioning
– Spacing – abnormal, altered, decreased, increased
– Incomplete dislocation
– Rotation
– Listhesis – antero, postero, retro, lateral, spondylo
– Motion – limited, lost, restricted, flexion, extension, hyper mobility, hypomotility, aberrant

Other terms may be used. If they are understood clearly to refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.

Treatment Parameters

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.

Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already “set” and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.

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 and reimbursement under Medicare will be limited to not more than one treatment per day.

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.



Chiropractic Manipulative Treatment Denials




Denial Reason, Reason/Remark Code(s)

CO-18 – Duplicate Service(s): Same service submitted for the same patient, same date of service by same doctor will be denied as a duplicate

CO-151 – Information provided does not support this many/frequency of services. Same service submitted for the same patient, same date of service by the same provider will be denied.

CPT codes: 98940, 98941, 98942

Resolution/Resources

First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA eServices tool or by calling the Palmetto GBA Interactive Voice Response (IVR) unit.

Please note:

Only one chiropractic manipulative treatment will be allowed per day


Billing Information

Procedure codes 97260 and 97261 have been deleted in the Current Procedural Terminology manual (Procedure ). Chiropractors are to bill for services using the appropriate, current Procedure code (98940 or 98941) for the service provided. HCPCS modifier “AT” (Acute Treatment) may be appended.

Claims for chiropractic services pend to Medical Review and must be submitted hardcopy. The claim is to be accompanied by a written, dated, and signed referral statement from EPSDT medical screening provider or PCP and documentation substantiating the medical necessity of the services. The documentation should include, but is not limited to:

• Diagnosis and chief complaint

(Video) Sam's Chiropractic Corner- Modifier 59

• Relevant history

• Subjective and objective diagnostic examination findings

• Acuity and severity of the patient’s condition

• Results of X-ray, lab and other diagnostic tests

• Number of treatment sessions necessary to correct or alleviate the patient’s symptoms or problem

• The level of care (relief, therapeutic, rehabilitative, supportive) planned

• Procedures performed and results

• Response to therapy

• Progress notes and patient disposition


Beneficiary Responsibility

For Medicare covered services, the beneficiary pays the Part B deductible and then 20 percent of the Medicare-approved amount. The beneficiary also pays all costs for any services or tests you order. If you provide an ABN, you must submit a claim to Medicare, even though you expect the beneficiary to pay and you expect Medicare to deny the claim.

CPT describes chiropractic manipulative treatment (CMT) as, “…a form of manual treatment to influence joint and neurophysiologic function. This treatment may be accomplished using a variety of techniques.” A series of three CMT codes (98940, 98941, 98942) has been developed to describe the number of spinal regions receiving manipulation. A single extraspinal CMT code (98943) is used by chiropractors to describe manipulative services directed at the head, extremities, rib cage, and abdomen.

Correct coding emphasizes that procedures should be reported with the CPT codes that most comprehensively describe the services performed e.g., 98941 is a more comprehensive code than 98940. There are procedural codes that are not to be reported together because they are mutually exclusive to each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session. An example of mutually exclusive codes germane to this policy is 97140 – Manual therapy techniques (without the -59 modifier) vs. 98940, 98941, 98942, or 98943 – Chiropractic manipulative treatment.

Chiropractic Manipulative Treatment (CMT)


CPT CPT Description Reimbursement Policy

98940 CMT; spinal, one to two regions

98941 CMT; spinal, three to four regions

98942 CMT; spinal, five regions

Indications


Chiropractic Services – Active Treatment:

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 following categories:

Acute subluxation – A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.

Chronic subluxation – A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is causing significant interference with activities of daily living due to an acute flare-up of the previously treated condition. The patient’s clinical record must specify the date of occurrence, nature of the onset, or other pertinent factors that would support the medical necessity of treatment. As with an acute injury, treatment should result in improvement or arrest of the deterioration within a reasonable period of time.

A. Maintenance Therapy

Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.


B. Contraindications

Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart.

The following are relative contraindications to Dynamic thrust:

Articular hyper mobility and circumstances where the stability of the joint is uncertain;
Severe demineralization of bone;
Benign bone tumors (spine);
Bleeding disorders and anticoagulant therapy; and
Radiculopathy with progressive neurological signs.
Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:

Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
An unstable os odontoideum;
Malignancies that involve the vertebral column;
Infection of bones or joints of the vertebral column;
Signs and symptoms of myelopathy or cauda equina syndrome;
For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and
A significant major artery aneurysm near the proposed manipulation.

Limitations

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.

Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

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.

The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for the treatments. The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s). The need for an extensive, prolonged course of treatment should be appropriate to the reported procedure code(s) and must be documented clearly in the medical record.

The five extraspinal regions referred to are: head (including, temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib care (excluding costotransverse and costovertebral joints) and abdomen . Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage 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 and the LCD. Modifier AT must not be used when maintenance therapy has been performed.



Billing and Coding Guidelines.

Payment is allowed for one clinically indicated and medically necessary spinal manipulation code per date of service. Reimbursement of specific CMT codes is subject to the subscriber certificate.




Extraspinal Manipulation + Spinal Manipulation
Modifier -51 (Multiple Procedures) is not required to be appended to the extraspinal CMT procedural code (98943), when billed on
the same date of service as a spinal CMT code (98940-98942).

It is not appropriate to use modifier 52 with any of the CMT codes or timed therapy codes.

• Modifier 52 identifies a reduced service but should not be used to identify another procedure if there is a specific CPT® code for the reduced service.

• Codes for spinal manipulations (98940 – 98942) are specific to the number of regions treated. If only two regions are treated, 98940 should be used instead of 98941–52

Claims submitted for CPT code 98940, 98941, or 98942 with the demonstration code “demo 45” shall be rejected.

Effective immediately, carrier(s) shall educate chiropractors in the four demonstration sites that current Medicare coverage policies for codes 98940, 98941, and 98942 remain in effect. Chiropractors will continue to be paid according to the current fee schedule rate for these three codes.

Chiropractors must apply demonstration code 45 to all demonstration claims. On the 837 professional transaction, chiropractors should report the demonstration number “45” in Loop 2300 REF02 (REF01=P4). If chiropractors are using the CMS-1500 claim form, the demonstration number should be inserted in Box 19 (reserved for local use) along with the word “demo” before the number 45

You will be required to submit claims for demonstration services separately from claims for CPT codes 98940, 98941, and 98942. For example, if you submit claims for CPT codes 98940 through 98942 with demonstration services and the demonstration code 45, the non-demonstration services will be rejected and you will have to resubmit the non-demonstration services. The demonstration services will be paid

If you submit a claim for CPT codes 98940 through 98942 with demonstration services and the demonstration code 45 is not included, the demonstration services will be rejected and you should resubmit them as a separate claim. The non-demonstration services will be paid in this instance.

Chiropractors should also be aware that they will be subject to the current version of the National Correct Coding Edits (CCI) which can be found at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.
Other points of interest to you are as follows:

• CPT codes currently exist for the services that you will provide under this demonstration (See Tables 5 and 6). Your Medicare carrier will develop edits to recognize chiropractors in these four geographic areas and allow you to be reimbursed for your authorized medical, radiology, clinical lab, and therapy services. Information regarding fees for demonstration services (except 98943, which is found in Table 1) can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/index.html on the CMS website.

• Current Medicare coverage for chiropractic services (codes 98940, 98941, and 98942) remains unchanged. The fee schedule for these three codes will continue to apply.

Medicare Coding and Billing

* The procedure codes that chiropractors use to bill covered procedures to Medicare are: o 98940 o 98941 o 98942

(Video) ChiroSecure & HJ Ross CPT modifier update

GA Modifier

* The GA code signifies the “Waiver of Liability Statement Issued as Required by Payer Policy.”

* The GA modifier does not signify that the care is maintenance.

* If you place the GA modifier on a code you must have a signed ABN form in the file.

* It is appropriate to report the GA modifier when the beneficiary refuses to sign the ABN.

* For chiropractors, the –AT modifier (which signifies that the patient is under active treatment and that improvement is expected) is only used with the procedure codes 98940, 98941 and 98942.

* With the new changes in effect, the –GA modifier can only be used with procedure codes 98940, 98941 and 98942.

Billing With E & M code

E&M is necessary when performing the initial exam. An E&M service may once again be necessary if there is a change in condition or treatment protocol.

It is not appropriate to bill for routine scheduled E&M service (every 12 days of treatment).

Use modifier 25 to identify the E&M service separately when performed with CMT.

Documentation must be complete as to the level of E&M services provided according to CPT® guidelines.

CMT codes include a pre-manipulation patient assessment component for each visit, which must be supported by appropriate documentation. Therefore, it is not appropriate to bill an E&M service with each CMT service. If billed inappropriately, the E&M service will be denied as provider liable.

It is appropriate to bill for the CMT and E&M service if one of the following has occurred: • A new patient visit • An established patient visit. The established patient must have a new condition, new injury, aggravation, or exacerbation which warrants further examination above and beyond what is included in CMT services

Payment for manual manipulation of the spine is limited to one manipulation per day and may not exceed 12
manipulations per calendar year. Effective for dates of service on or after January 1, 2005, North Dakota Medicaid
will allow reimbursement to chiropractors for Evaluation and Management (E/M)office and other outpatient
Services – New Patient (99201-99203). These E/M services may be billed in addition to the chiropractic manipulative
treatment (98940-98942) ONLY when the patient has not received any professional (face-to-face) services from the
chiropractor, or another chiropractor of the same group practice, within the past three years.


Background

In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service (FFS) program reported a 54 percent error rate on claims for chiropractic services. The majority of thoseerrors were due to insufficient documentation or other documentation errors.

Medicare coverage of chiropractic services is specifically limited to treatment by means of manual manipulation (that is, by use of the hands) of the spine to correct a subluxation. The patient must require treatment by means of manual manipulation of the spine to correct a subluxation, 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. Additionally, manual devices (that is, those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

Chiropractors are limited to billing three Current Procedural Terminology (CPT®) codes under Medicare: 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), and 98942 (five regions).When submitting manipulation claims, chiropractors must use an acute treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation. The AT modifier, when applied appropriately, should indicate expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.

Documentation requirements

The Social Security Act states that “no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the mounts are being paid or for any prior period..

Medical record must document:
1. A complaint involving at least three spinal regions;
2. an examination of the corresponding spinal regions; AND
3. a diagnosis and manipulative treatment of conditions involving at least three spinal regions.
Claim must record a diagnosis codes (ICD-9) in all the applicable regions

Medicare Advantage Policy and Medicare Cost Plan

Medicare coverage of chiropractic services is specifically limited to treatment by means of manual manipulation of the spine to correct a subluxation.

Chiropractors are limited to billing three Current Procedural Terminology (CPT) codes under Medicare: 98940, 98941and 98942 When submitting manipulation claims, chiropractors must use an Acute Treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation. The AT modifier, when applied appropriately, should indicate expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.

Medicare does not cover chiropractic treatment to extraspinal regions (98943) which includes the head, upper and lower extremities, rib cage and abdomen

General Guidelines

All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors. A valid diagnosis is the most appropriate ICD-9-CM code that is supported by subjective symptoms, physical findings, and diagnostic testing/imaging (if appropriate)…

Documentation should be recorded on the day of the patient visit and include all of the following:

1. a subjective record of the patient complaint i.e., location, quality, and intensity

2. physical findings to support manipulation in a region or segment e.g., regional/segmental asymmetry or misalignment,
range of motion abnormality, soft tissue tone and/or tenderness characteristics

3. assessment of change in patient condition, as appropriate

4. a record of the specific segments manipulated 98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions Documentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT).

98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions Documentation must support that manipulative treatment occurred in three to four regions of the spine (region as defined by CPT) and one of the following:

1. validated diagnoses for three or four spinal regions

2. validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings 98942 Chiropractic manipulative treatment (CMT); spinal, five regions Documentation must support that manipulative treatment occurred in five regions of the spine (region as defined by CPT) and one of the following:

1. validated diagnoses for five spinal regions

2. validated diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings

3. validated diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings 98943 Chiropractic manipulative treatment (CMT); extraspinal, one to five regions


Medicare Coverage of Chiropractic Services

Coverage of chiropractic services is specifically limited to treatment by means of manual manipulation (i.e., by use of the hands) of the spine to correct a subluxation. Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine, are altered, although contact between joint surfaces remains intact.
Manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. No additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered. If you order, take, or interpret an x-ray, or any other diagnostic test, the x-ray or other diagnostic test can be used for documentation, but Medicare coverage and payment are not available for those services. This does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program.

Subluxation May Be Demonstrated by X-Ray or Physician’s Examination

Physical examination

To demonstrate a subluxation based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required:

1. Pain/tenderness evaluated in terms of location, quality, and intensity;

2. Asymmetry/misalignment identified on a sectional or segmental level;

3. Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility); and

4. Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.

Documentation Requirements Must Be Placed in the Patient’s File

Initial Visit

(Video) Chiropractic Billing vs. Medical Billing

The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. The history includes the following:

a. Symptoms causing patient to seek treatment;

b. Family history if relevant;

c. Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);

d. Mechanism of trauma;

e. Quality and character of symptoms/problem;

f. Onset, duration, intensity, frequency, location, and radiation of symptoms;

g. Aggravating or relieving factors; and

h. Prior interventions, treatments, medications, secondary complaints.

2. Description of the present illness, including:

a. Mechanism of trauma;

b. Quality and character of symptoms/problem;

c. Onset, duration, intensity, frequency, location, and radiation of symptoms;

d. Aggravating or relieving factors;

e. Prior interventions, treatments, medications, secondary complaints; and

f. Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

3. Evaluation of musculoskeletal/nervous system through physical examination

4. Diagnosis

The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.

5. Treatment Plan should include the following:

a. Recommended level of care (duration and frequency of visits);

b. Specific treatment goals; and

c. Objective measures to evaluate treatment effectiveness.

6. Date of the initial treatment.

7. The patient’s medical record.

• Validate all of the information on the face of the claim, including the patient’s reported diagnosis(s), physician work (CPT code), and modifiers.

• Verify that all Medicare benefit and medical necessity requirements were met.

Subsequent Visits

The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. History

a. Review of chief complaint;

b. Changes since last visit; and

c. Systems review if relevant.

2. Physical examination

a. Examination of area of spine involved in diagnosis;

b. Assessment of change in patient condition since last visit;

c. Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

Necessity for Treatment


Acute and Chronic Subluxation

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 examination, as described above.

Most spinal joint problems fall into the following categories:

• Acute subluxation–A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical examination as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.

• Chronic subluxation–A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.



Medicare Coding and Billing

** The CMS-1500 form (or its electronic equivalent) is how we communicate with our local Part B Medicare Administrative Contractor the services we have performed and why we performed them.
** You are talking to a computer and all that it knows is what you tell it through the numbers that you put on the 1500 Form.
** There are two code sets that are used to communicate information to the MAC.
o ICD-9-CM codes.
o CPT codes.
** ICD-9-CM stands for International Classification of Disease, 9th edition, Clinical Modification.
** We covered diagnosis in another webinar.
** CPT® stands for Current Procedural Terminology®
** The CPT® Code Set is owned by the American Medical Association.
** This is why there is a delay in the implementation of the ICD-10 codes.
** The ICD-10 codes are used both for diagnosis and procedures coding.
** The procedure codes that chiropractors use to bill covered procedures to Medicare are:
o 98940
o 98941
o 98942
** Remember that the only Medicare covered procedure for chiropractors is the adjustment.
** The only reason to bill any other procedure would be at the request of the patient and then only if they have a secondary insurance that would require a denial from Medicare before they paid for the service.

AT Modifier

** “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 an 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.”
** The AT modifier must be on all active treatment services for correction of acute and chronic subluxations.
** If you have a signed ABN on file but are still in active treatment, use the AT,GA modifier combination in that order.
** Do Not use the AT modifier for care that is maintenance in nature. GA Modifier
** The GA code signifies the “Waiver of Liability Statement Issued as Required by Payer Policy.”
** The GA modifier does not signify that the care is maintenance.
** If you place the GA modifier on a code you must have a signed ABN form in the file.
** It is appropriate to report the GA modifier when the beneficiary refuses to sign the ABN.
** For chiropractors, the –AT modifier (which signifies that the patient is under active treatment and that improvement is expected) is only used with the procedure codes 98940, 98941 and 98942.
** With the new changes in effect, the –GA modifier can only be used with procedure codes 98940, 98941 and 98942. GY Modifier
** The GY modifier is used to indicate that a service is not covered by Medicare
** Use the GY modifier when a patient’s secondary insurance needs a rejection by Medicare before they will pay for a service GZ Modifier
** The GZ modifier is used when you expect Medicare to deny the service and you do not have an ABN form signed.
** Use this modifier when you forgot the ABN.
** Expect an audit if you use this modifier Q6 Modifier
** Services provided by a Locum Tenens physician
** Use this modifier when you have another doctor filling in for you.
** A Locum Tenens doctor can fill in for 60 days.

ICD-10 CODE DESCRIPTION
M99.00 Segmental and somatic dysfunction of head region
M99.01 Segmental and somatic dysfunction of cervical region
M99.02 Segmental and somatic dysfunction of thoracic region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.05 Segmental and somatic dysfunction of pelvic region
M99.10 Subluxation complex (vertebral) of head region
M99.11 Subluxation complex (vertebral) of cervical region
M99.12 Subluxation complex (vertebral) of thoracic region
M99.13 Subluxation complex (vertebral) of lumbar region
M99.14 Subluxation complex (vertebral) of sacral region
M99.15 Subluxation complex (vertebral) of pelvic region


Group 2 codes

G44.1 Vascular headache, not elsewhere classified
G44.209 Tension-type headache, unspecified, not intractable
G44.219 Episodic tension-type headache, not intractable
G44.229 Chronic tension-type headache, not intractable
M24.50 Contracture, unspecified joint
M47.10 Other spondylosis with myelopathy, site unspecified
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.819 Spondylosis without myelopathy or radiculopathy, site unspecified
M47.891 Other spondylosis, occipito-atlanto-axial region
M47.892 Other spondylosis, cervical region
M47.893 Other spondylosis, cervicothoracic region
M47.894 Other spondylosis, thoracic region
M47.895 Other spondylosis, thoracolumbar region
M47.896 Other spondylosis, lumbar region
M47.897 Other spondylosis, lumbosacral region
M47.898 Other spondylosis, sacral and sacrococcygeal region
M48.10 Ankylosing hyperostosis [Forestier], site unspecified
M48.11 Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region
M48.12 Ankylosing hyperostosis [Forestier], cervical region
M48.13 Ankylosing hyperostosis [Forestier], cervicothoracic region
M48.14 Ankylosing hyperostosis [Forestier], thoracic region
M48.15 Ankylosing hyperostosis [Forestier], thoracolumbar region
M48.16 Ankylosing hyperostosis [Forestier], lumbar region
M48.17 Ankylosing hyperostosis [Forestier], lumbosacral region
M48.18 Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal region
M48.19 Ankylosing hyperostosis [Forestier], multiple sites in spine
M54.2 Cervicalgia
M54.5 Low back pain
M54.6 Pain in thoracic spine
M54.89 Other dorsalgia
M54.9 Dorsalgia, unspecified
R51 Headache

(Video) Sam's Chiropractic Corner- United Healthcare Denials

FAQs

CPT CODES – 98940, 98941, 98943, 98942 – Chiropractic billing with AT modifer? ›

Chiropractors are limited to billing three Current Procedural Terminology (CPT) codes under Medicare: 98940, 98941and 98942 When submitting manipulation claims, chiropractors must use an Acute Treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation.

What modifier should be used with 98943? ›

Maintenance or Palliative Care and Modifier AT Use

The “AT” modifier distinguishes active/corrective treatment from maintenance therapy. The AT modifier should be appended to the chiropractic manipulation (98940-98943) to show active treatment.

Does 98941 need a modifier? ›

When providing maintenance therapy, no modifier is required when billing procedure codes 98940, 98941, or 98942. 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.

What does CPT code 98940 mean? ›

CPT Code 98940 - Chiropractic manipulative treatment (CMT); spinal, 1-2 regions. CPT Code 97110 – Therapeutic Exercise.

What CPT code is 98941? ›

CPT Code 98941 Chiropractic manipulative treatment (CMT); Spinal, 3-4 regions.

Can 98941 and 98943 be billed together? ›

If an authorization is submitted for 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions, but the doctor provides and bills 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions, the claim will be denied.

Does CPT code 98943 need a modifier? ›

Simply code it as 98943, no modifiers necessary. Make sure that you have an appropriate diagnosis code that reflects the extremity problem.

What modifiers are needed for chiropractic billing? ›

Modifiers in Chiropractic Medical Billing:
  • Modifier 25. Modifier 25 is utilized to show that this is an important, independently recognizable evaluation and management (E/M) service by the same physician on the same day. ...
  • GA Modifier. ...
  • GY Modifier. ...
  • Modifier 59. ...
  • X-set Modifiers. ...
  • The Active Treatment (AT) Modifier.
May 25, 2020

What modifiers do chiropractors use? ›

Modifier 59: (Distinct Procedural Service) : This is one of the most important chiropractic modifiers for chiropractors. It is used to distinguish an important, recognizable non-E/M service that was performed by the same provider on the same day.

Can chiropractors use GP modifier? ›

GP is the most appropriate for chiropractic claims, as it aligns with the therapy provider “physical therapy”.

What CPT codes can a chiropractor bill? ›

Documentation requirements

Claims submitted for Chiropractic Manipulative Treatment (CMT) CPT codes 98940, 98941, or 98942, (found in Group 1 codes under CPT/HCPCS Codes) must contain an AT modifier or they will be considered not medically necessary.

What CPT codes are covered by Medicare for chiropractic? ›

Doctors of chiropractic are limited to billing three Current Procedural Terminology (CPT) codes under Medicare: 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), and 98942 (five regions).

Can a chiropractor bill physical therapy codes? ›

He can and does bill out PT codes when/if he performs physical therapy services.

Does G0283 need modifier? ›

Medicare does need the modifier GP appended to G0283, just like the other therapy chgs require mod GP.

Can a chiropractor bill 99212? ›

If there is a true evaluation, then it will likely meet the criteria for 99212 because it's fairly straightforward. Billing low-level E/M codes to stay under the radar, such as 99202, without understanding the coding rules, implies the nature of the presenting problem must not be very severe.

Is CPT 98940 covered by Medicare? ›

Other Policies and Guidelines may apply. Diagnosis Code Description Medicare Covered Chiropractic Services If the CPT code is 98940, 98941, or 98942 and is billed with one of the following primary diagnosis codes and with modifier AT, then the chiropractic service is covered.

Does 97010 need a modifier? ›

This policy change requires that claims with physical medicine services 97010-97799 will require modifier GP. The modifier is required for dates of service after April 1, 2021. Any PT now billed to Anthem will require the GP modifier.

Can a chiropractor bill 97140? ›

American Medical Association (AMA) coding guidelines dictate that it is only appropriate to bill for Chiropractic Manipulative Treatment (CMT) and manual therapy (CPT code 97140) for the same patient on the same visit under certain circumstances.

Can a chiropractor bill 97124? ›

Now chiropractors must be paid for neuromuscular reeducation (97112), massage (97124), and manual therapy (97140) when “performed on separate anatomic sites or at separate patient encounters on the same date of service as a chiropractic manipulative treatment (98940—98942).” This was perhaps the biggest reimbursement ...

Does Medicare cover CPT code 98943? ›

Non-Covered Services:

Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage, and abdomen.

What is the multiple surgery modifier? ›

Modifier 51 is defined as multiple surgeries/procedures. Multiple surgeries performed on the same day, during the same surgical session. Diagnostic Imaging Services subject to the Multiple Procedure Payment Reduction that are provided on the same day, during the same session by the same provider.

What is Extraspinal chiropractic manipulative treatment? ›

Extraspinal manipulation, also known as extraspinal manipulative therapy (EMT), is used to treat joint dysfunction outside of the vertebral column.

Is 98940 covered by Medicare? ›

Other Policies and Guidelines may apply. Diagnosis Code Description Medicare Covered Chiropractic Services If the CPT code is 98940, 98941, or 98942 and is billed with one of the following primary diagnosis codes and with modifier AT, then the chiropractic service is covered.

Chiropractic modifiers are reported along with CPT codes to tell the payer that that there something is unique about the services being billed.

Medical billing outsourcing companies that provide chiropractic billing services found that most of the claims denied were those that required the 25 and 59 modifiers.. Chiropractic modifiers are reported along with CPT codes to tell the insurance company that there is something unique about the services being billed.. On the other hand, if codes that require a modifier are billed without one, the carrier will reject the claim with an explanation on the EOB of bundling with another service.. Let’s take a look at the use of modifiers 25 and 59 when reporting chiropractic services.. Additional evaluation and management (E/M) services may be reported separately using modifier 25, if the patient’s condition requires a separate E/M service, above and beyond the usual pre-service and post-service.. So if manipulation and E/M codes are billed for the same visit, it is necessary to attach modifier 25 modifier to the E/M code.. Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day.. Modifier XS: Separate structure—the service is distinct because it was performed on a separate organ or structure.. Modifier XP: Separate practitioner—the service is distinct because it was performed by a different practitioner.. 97140 – Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. For e.g., one service may be performed during the initial 15minutes of therapy and the other service performed during the second 15 minutes of therapy.. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.. Before using NCCI-associated modifiers, DCs should check with their local Medicare carrier for guidance.. Outsourcing chiropractic medical billing and coding is a practical option to ensure that chiropractic services billed to Medicare and other payers are medically necessary, correctly coded and adequately documented.. Coders and billing specialists in experienced medical billing outsourcing companies work alongside DCs to understand that specific ways chiropractic services are reimbursed, promoting accurate claim submission, reduced risk of scrutiny and denials, and optimal reimbursement.

Number: 0107

Active Release Technique (see CPB 0388 - Complementary and Alternative Medicine ); Active Therapeutic Movement (ATM2); Advanced Biostructural Correction (ABC) Chiropractic Technique; Applied Spinal Biomechanical Engineering; Atlas Orthogonal Technique; Bioenergetic Synchronization Technique; Biogeometric Integration; Blair Technique; Bowen Technique; Chiropractic Biophysics Technique / Chiropractic BioPhysics Methods; Coccygeal Meningeal Stress Fixation Technique; ConnecTX (an instrument-assisted connective tissue therapy program); Cox decompression manipulation/technique; Cranial Manipulation; Directional Non-Force Technique; FAKTR (Functional and Kinetic Treatment with Rehab) Approach; Gonzalez Rehabilitation Technique; Inertial traction (inertial extensilizer decompression table; IntraDiscNutrosis program; Koren Specific Technique; Manipulation for infant colic; Manipulation for internal (non-neuromusculoskeletal) disorders (Applied Kinesiology); Manipulation Under Anesthesia (see CPB 0204 - Manipulation Under General Anesthesia ); Moire Contourographic Analysis; Network Technique; Neural Organizational Technique; Neuro Emotional Technique; NUCCA (National Upper Cervical Chiropractic Association) procedure; Origin insertion release technique; Positional release therapy; Sacro-Occipital Technique; Spinal Adjusting Devices (ProAdjuster, PulStarFRAS, Activator); Therapeutic (Wobble) Chair; Upledger Technique and Cranio-Sacral Therapy; Webster Technique (for breech babies); Whitcomb Technique (see CPB 0388 - Complementary and Alternative Medicine );. Table: 98940Chiropractic manipulative treatment (CMT); spinal, one to two regions98941 spinal, three to four regions98942 spinal, five regions98943 extraspinal, one or more regions22505Manipulation of spine requiring anesthesia, any region 97530Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes [not covered for FAKTR]20552Injection(s); single or multiple trigger point(s), one or two muscle(s)20553 single or multiple trigger point(s), three or more muscle(s)20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) 20561 3 or more muscles 95836 - 95857Muscle and range of motion testing95860 - 95887Electromyography and nerve conduction tests 95907 - 95913Nerve conduction studies95937Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method96000 - 96004Motion analysis97010 - 97799Physical medicine and rehabilitation Home-based chiropractic service - no specific codeG0151Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutesS3900Surface electromyography (EMG)S9131Physical therapy; in the home, per diemG24.3Spasmodic torticollisG54.0 - G55Nerve root and plexus disordersG71.0 - G72.9Primary disorders of muscles and other myopthiesG80.0 - G80.9Cerebral palsyM05.00 - M08.99Rheumatoid arthritis and other inflammatory polyarthropathiesM40.00 - M40.51, M42.00 -M54.9Deforming dorsopathies, spondylitis and other dorsopathies [excluding scoliosis]M91.10 - M94.9ChondropathiesQ65.00 - Q68.8Congenital musculoskeletal deformitiesQ72.70 - Q72.73, Q74.1 - Q74.2Congenital malformations of lower limb, including pelvic girdleQ74.0, Q74.9, Q87.89Congenital malformations of upper limb, including shoulder girdleQ76.0 - Q76.49Congenital malformations of spineQ77.0 -Q77.1Q77.4 - Q77.5Q77.7 - Q77.9Q78.9OsteochrondrodysplasiaS03.4xx+Sprain of jawS13.0xx+ - S13.9xx+, S23.0xx+ - S23.9xx+, S33.0xx+ - S33.9xx+, S43.001+ - S43.92X+, S53.001+ - S53.499, S63.001+ - S63.92X+, S73.001+ - S73.199+, S83.001 - S83.92X+, S93.01X+ - S93.699+Dislocation and sprains of joint and ligamentsS14.2xx+ - S14.9xx+, S24.2xx+ - S24.9XX+, S34.21x+ - S34.9XX+Injury to nerve roots, spinal plexus and other nervesS16.1xx+Strain of muscle, fascia and tendon at neck levelS23.41x+ - S23.429+, S33.4xx+S33.8xx+ - S33.9xx+Sprain of other ribs, sternum, and pelvisS39.002+, S39.012+, S39.092+Injury or strain of muscle, fascia and tendon of lower backS44.00x+ - S44.92x+Injury of nerves at shoulder and upper arm levelS46.011+ - S46.019+, S46.111+ - S46.119+, S46.211+ - S46.219+, S46.311+ - S46.319+, S46.811+ - S46.819+, S46.911+ - S46.919+Injury of muscle, fascia and tendon at shoulder and upper arm levelS74.00x+ - S74.92x+Injury of nerves at hip and thigh levelS76.011+ - S76.019+, S76.111+ - S76.119+, S76.211+ - S76.219+, S76.311+ - S76.319+, S76.811+ - S76.819+, S76.911+ - S76.919+Injury and strain of muscle, fascia and tendon at hip and thigh levelS84.00x+ - S84.92x+Injury of nerves at lower leg levelS86.001+ - S86.019+, S86.111+ - S86.119+, S86.211+ - S86.219+, S86.311+ - S86.319+, S86.811+ - S86.819+, S86.911+ - S86.919+Injury of muscle, fascia and tendon at lower leg level S94.00x+ - S94.92x+Injury of nerves at ankle and foot levelS96.001+ - S96.019+, S96.111+ - S96.119+, S96.211+ - S96.219+, S96.811+ - S96.819+, S96.911+ - S96.919+Injury of muscle, fascia and tendon at ankle and foot levelG24.3Spasmodic torticollisG43.001 - G43.919MigraineG44.001 - G44.89Tension and other headachesG54.0 - G55Nerve root and plexus disordersG56.00 - G56.93Mononeuritis of upper limb G57.00 - G59Mononeuritis of lower limbG71.00 - G72.9Muscular dystrophies and other myopathiesG80.0 - G80.9Cerebral palsyM05.00 - M08.99Rheumatoid arthritis and other inflammatory polyarthropathiesM12.00 - M13.89Other and unspecified arthropathiesM15.0 - M19.93Osteoarthritis and allied disordersM20.001 - M25.9Other joint disordersM26.601 - M26.69Temporomandibular joint disordersM35.3, M75.00 - M79.9Rheumatism, shoulder lesions and enthesopathies [excludes back]M40.00 - M40.51, M42.00 - M54.9Deforming dorsopathies, spondylitis and other dorsopathies [excluding scoliosis]M85.30 - M85.39Osteitis condensansM89.00 - M89.09AlgoneurodystrophyM91.10 - M94.9OsteochondropathiesM95.3Acquired deformity of neckM95.5Acquired deformity of pelvisM95.8Other specified acquired deformities of musculoskeletal systemM95.9Acquired deformities of musculoskeletal system, unspecifiedM99.00 - M99.09Segmental and somatic dysfunction [allowed by CMS]M99.10 - M99.19Subluxation complex (vertebral)M99.83 - M99.84Other acquired deformity of back or spineNumerous optionsOther, multiple, and ill-defined dislocations [including vertebra]Q65.00 - Q68.8Congenital musculoskeletal deformitiesQ74.1 - Q74.2Congenital malformations of lower limb, including pelvic girdleQ74.0, Q74.9, Q87.89Congenital malformations of upper limb, including shoulder girdleQ76.0 - Q76.49Congenital malformations of spineQ77.0 -Q77.1Q77.4 - Q77.5Q77.7 - Q77.9Q78.9 OsteochrondrodysplasiaR51HeadacheS03.40x+ - S03.42x+Sprain of jawS13.0xx+ - S13.9xx+, S23.0xx+ - S23.9xx+, S33.0xx+ - S33.9xx+, S43.001+ - S43.92X+, S53.001+ - S53.499, S63.001+ - S63.92X+, S73.001+ - S73.199+, S83.001 - S83.92X+, S93.01X+ - S93.699+Dislocation and sprains of joints and ligamentsS14.2xx+ - S14.9xx+, S24.2xx+ - S24.9XX+S34.21x+ - S34.9xx+ Injuries to nerve root(s), spinal plexus(es) and other nerves S16.1xx+Strain of muscle, fascia and tendon at neck levelS23.41x+ - S23.429+, S33.4xx+S33.8xx+ - S33.9xx+Sprain of other ribs, sternum, and pelvisS39.002+, S39.012+, S39.092+Injury or strain of muscle, fascia and tendon of lower backS44.00x+ - S44.92x+Injury of nerves at shoulder and upper arm levelS46.011+ - S46.019+, S46.111+ - S46.119+, S46.211+ - S46.219+, S46.311+ - S46.319+, S46.811+ - S46.819+, S46.911+ - S46.919+Injury of muscle, fascia and tendon at shoulder and upper arm levelS74.00x+ - S74.92x+Injury of nerves at hip and thigh levelS76.011+ - S76.019+, S76.111+ - S76.119+, S76.211+ - S76.219+, S76.311+ - S76.319+, S76.811+ - S76.819+, S76.911+ - S76.919+Injury and strain of muscle, fascia and tendon at hip and thigh levelS84.00x+ - S84.92x+Injury of nerves at lower leg levelS86.001+ - S86.019+, S86.111+ - S86.119+, S86.211+ - S86.219+, S86.311+ - S86.319+, S86.811+ - S86.819+, S86.911+ - S86.919+Injury of muscle, fascia and tendon at lower leg level S94.011+ - S94.019+, S94.111+ - S94.119+, S94.211+ - S94.219+, S94.311+ - S94.319+, S94.811+ - S94.819+, S94.911+ - S94.919+Injury of nerves at ankle and foot levelS96.001+ - S96.019+, S96.111+ - S96.119+, S96.211+ - S96.219+, S96.811+ - S96.819+, S96.911+ - S96.919+Injury of muscle, fascia and tendon at ankle and foot levelF32.0 - F32.9Major depressive disorder, single episodeF33.0 - F33.9 Major depressive disorder, recurrentF84.0 - F84.9Pervasive developmental disorderF90.0 - F90.9Attention deficit hyperactivity disorderG40.001 - G40.919Epilepsy and recurrent seizuresH81.01 - H81.49 VertigoJ45.20 - J45.998AsthmaK00.0 - K95.89Diseases of the digestive systemM41.00 - M41.9Scoliosis [and kyphoscoliosis], idiopathic; resolving infantile idiopathic scoliosis; and progressive infantile idiopathic scoliosisN94.4 - N94.6DysmenorrheaN95.1Menopausal and female climacteric states [not covered for menopause-associated vasomotor symptoms]N97.0 - N97.9 Female infertilityO32.1xx0 - O32.1xx9Maternal care for breech presentationR10.83ColicR42 Dizziness and giddinessR56.1Post traumatic seizuresR56.9Unspecified convulsions [seizure disorder NOS] Chiropractic is a branch of the healing arts that is concerned with human health and prevention of disease, and the relationship between the neuroskeletal and musculoskeletal structures and functions of the body.. In another publication, Haas et al (2004) reported on a randomized controlled pilot study conducted in the faculty practice of a chiropractic college outpatient clinic examining the effects of the number of chiropractic treatment visits for manipulation with and without physical modalities on chronic low back pain and disability.. An unpublished study (Pfefer et al, 2007) compared the outcomes in terms of pain and function of acute low back pain patients treated with either Activator Methods Chiropractic Technique or a standard method of chiropractic manipulation (diversified chiropractic spinal manipulation).. Statistically significant improvements were observed in both groups from the 1st to 3rd, 3rd to 5th, and 1st to 5th consultations for improvements (p < 0.001) in mean numerical pain rating scale 101 (group 1, 49.1 to 23.4; group 2, 48.9 to 22.5), revised Oswestry Low Back Pain Disability Questionnaire (group 1, 37.4 to 18.5; group 2, 36.6 to 15.1), orthopedic rating score (group 1, 7.6 to 0.6; group 2, 7.5 to 0.8), and algometry measures (group 1, 4.8 to 6.5; group 2, 5.0 to 6.8) for first to last visit for both groups.

Use this page to view details for the Local Coverage Article for billing and coding: chiropractic services.

Contractor NameContract TypeContract NumberJurisdictionStates Novitas Solutions, Inc. A and B MAC. 04111 - MAC A. J - H. Colorado Novitas Solutions, Inc. A and B MAC. 04112 - MAC B. J - H. Colorado Novitas Solutions, Inc. A and B MAC. 04211 - MAC A. J - H. New Mexico Novitas Solutions, Inc. A and B MAC. 04212 - MAC B. J - H. New Mexico Novitas Solutions, Inc. A and B MAC. 04311 - MAC A. J - H. Oklahoma Novitas Solutions, Inc. A and B MAC. 04312 - MAC B. J - H. Oklahoma Novitas Solutions, Inc. A and B MAC. 04411 - MAC A. J - H. Texas Novitas Solutions, Inc. A and B MAC. 04412 - MAC B. J - H. Texas Novitas Solutions, Inc. A and B MAC. 04911 - MAC A. J - H. ColoradoNew MexicoOklahomaTexas Novitas Solutions, Inc. A and B MAC. 07101 - MAC A. J - H. Arkansas Novitas Solutions, Inc. A and B MAC. 07102 - MAC B. J - H. Arkansas Novitas Solutions, Inc. A and B MAC. 07201 - MAC A. J - H. Louisiana Novitas Solutions, Inc. A and B MAC. 07202 - MAC B. J - H. Louisiana Novitas Solutions, Inc. A and B MAC. 07301 - MAC A. J - H. Mississippi Novitas Solutions, Inc. A and B MAC. 07302 - MAC B. J - H. Mississippi Novitas Solutions, Inc. A and B MAC. 12101 - MAC A. J - L. Delaware Novitas Solutions, Inc. A and B MAC. 12102 - MAC B. J - L. Delaware Novitas Solutions, Inc. A and B MAC. 12201 - MAC A. J - L. District of Columbia Novitas Solutions, Inc. A and B MAC. 12202 - MAC B. J - L. District of Columbia Novitas Solutions, Inc. A and B MAC. 12301 - MAC A. J - L. Maryland Novitas Solutions, Inc. A and B MAC. 12302 - MAC B. J - L. Maryland Novitas Solutions, Inc. A and B MAC. 12401 - MAC A. J - L. New Jersey Novitas Solutions, Inc. A and B MAC. 12402 - MAC B. J - L. New Jersey Novitas Solutions, Inc. A and B MAC. 12501 - MAC A. J - L. Pennsylvania Novitas Solutions, Inc. A and B MAC. 12502 - MAC B. J - L. Pennsylvania Novitas Solutions, Inc. A and B MAC. 12901 - MAC A. J - L. DelawareDistrict of ColumbiaMarylandNew JerseyPennsylvania. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any. product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04. Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association.. CMS IOM Publication 100-02, Medicare Benefit Policy Manual , Chapter 15, Sections 30.5 Chiropractor’s Services, 240 Chiropractic Services – General, 240.1 – Coverage of Chiropractic Services, 240.1.1 – Manual Manipulation, 240.1.2 – Subluxation May Be Demonstrated by X-Ray or Physician’s Exam, 240.1.3 – Necessity for treatment, 240.1.4 – Location of Subluxation, and 240.1.5 – Treatment Parameters. Article TextThis Billing and Coding Article provides billing and coding guidance for Chiropractic Services.. Group 1 (12 Codes)It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.. CodeDescription. M99.00. Segmental and somatic dysfunction of head region. M99.01. Segmental and somatic dysfunction of cervical region. M99.02. Segmental and somatic dysfunction of thoracic region. M99.03. Segmental and somatic dysfunction of lumbar region. M99.04. Segmental and somatic dysfunction of sacral region. M99.05. Segmental and somatic dysfunction of pelvic region. M99.10. Subluxation complex (vertebral) of head region. M99.11. Subluxation complex (vertebral) of cervical region. M99.12. Subluxation complex (vertebral) of thoracic region. M99.13. Subluxation complex (vertebral) of lumbar region. M99.14. Subluxation complex (vertebral) of sacral region. M99.15. Subluxation complex (vertebral) of pelvic region. Complete absence of all Revenue Codes indicates. that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes.. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered.

Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.

Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services.. Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:Billing and Coding Guide This policy describes Optum’s requirements for reimbursement of CPT codes 98940, 98941, 98942 (Spinal Chiropractic Manipulative Treatment) and 98943 (Extraspinal Chiropractic Manipulative Treatment).The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.Extraspinal Manipulation + Spinal ManipulationModifier -51 (Multiple Procedures) is not required to be appended to the extraspinal CMT procedural code (98943), when billed on the same date of service as a spinal CMT code (98940-98942).. Modifier -51 (Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940- 98943).. 98940 Chiropractic manipulative treatment (CMT); spinal, one to two regionsDocumentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT).98941 Chiropractic manipulative treatment (CMT); spinal, three to four regionsDocumentation must support that manipulative treatment occurred in three to four regions of the spine (region as defined by CPT) and one of the following:1. validated diagnoses for three or four spinal regions2.. validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings CPT Code Description Documentation Requirement 98940 Chiropractic manipulative treatment (CMT) involving one to two spinal regions Medical record must document:1.. a diagnosis and manipulative treatment of a condition involving at least one spinal region.Claim must record a diagnosis code (ICD-9) in the applicable region(s).

Title: Chiropractic Services Policy #: MA10.004h Policy In accordance with the Centers for Medicare & Medicaid Services (CMS), chiropractic services are covered when both the established coverage criteria and the Medical Necessity criteria, listed in this policy, are met. COVERAGE CRITERIAChiropractic services performed by means of manual manipulation (i.e., by use of the hands) of the spine are covered for the purpose of correcting a confirmed acute subluxation as a result of a new injury demonstrated by x-ray or physical examination. The result of chiropractic manipulation is expected to be an improvement in or an arrest of the progression of the individual’s condition. Chiropractic spinal manipulation services are additionally covered for one of the following conditions and must be clearly documented and reflective of the individual’s symptoms and treatment history: Acute exacerbation is a temporary marked deterioration of the individual’s condition causing significant interference with the activities of daily living due to flare up of the previously treated condition. Recurrence of an acute condition is a temporary marked deterioration of the individual’s condition due to flare up of the condition being treated.​ A number of different terms maybe used to describe manual manipulation: Spine or spinal adjustment by manual means Spine or spinal manipulation Manual adjustment Vertebral manipulation or adjustment Chiropractic spinal manipulation treatments must be reported with a primary diagnosis code representing an acute subluxation as well as the acute treatment (AT) modifier. Services reported without one of these primary diagnosis codes and the AT modifier will be considered not covered. NOT COVEREDTreatment for chronic subluxation and maintenance therapy are not covered by the Company because these services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration. Chronic subluxation: An individual's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. Maintenance therapy: Is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or as a therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. In accordance with Medicare, chiropractic maintenance therapy is considered not covered. Therefore, it is not eligible for reimbursement consideration. 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 considered not covered. ABSOLUTE CONTRAINDICATIONSDynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following conditions and is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration. Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation, including acute rheumatoid arthritis and ankylosing spondylitis; Acute fractures and dislocations or healed fractures and dislocations with signs of instability; An unstable os odontoideum; Malignancies that involve the vertebral column; Infection of bones or joints of the vertebral column; Signs and symptoms of myelopathy or cauda equina syndrome; For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and A significant major artery aneurysm near the proposed manipulation. In accordance with Medicare, all other services, other than manual manipulation for the treatment of acute subluxation of the spine, are not covered by the Company, including, but not limited to, laboratory tests, office visits, supplies, traction, treatment of joint dysfunction outside of the vertebral column (i.e., extraspinal) and manual devices. Therefore, they are not eligible for reimbursement consideration. LIMITATIONSIn accordance with Medicare, this policy imposes diagnosis limitations and will cover up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulations per member per calendar year. Please note that despite covering up to these maximums, each individual's condition and response to treatment must warrant the number of services reported. It is not expected that individuals will routinely require the maximum covered number of services.Diagnoses that are considered medically necessary are displayed in four groups: it is not expected that more than the following number of treatments per diagnostic group will usually be required. A. Chiropractic manipulation treatments for Group A diagnoses are 12 visits. B. Chiropractic manipulation treatments for Group B diagnoses are 18 visits. C. Chiropractic manipulation treatments for Group C diagnoses are 24 visits. D. Chiropractic manipulation treatments for Group D diagnoses are 30 visits. For information related to Group A, Group B, Group C, and Group D diagnosis codes, please see the coding table. NOT MEDICALLY NECESSARY All other diagnoses other than those listed in groups A, B, C, and D are considered not medically necessary and, therefore, not covered. REQUIRED DOCUMENTATIONThe individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.The individual exhibiting a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment with the following required documentation, and manipulative services rendered must have a therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery: Individual’s health history Description of the present illness including the individual’s symptoms related to the level of subluxation Evaluation of the musculoskeletal/nervous system through physical examinination The precise level of the subluxation Xray, CT scan and/or MRI Treatment plan including duration and frequency of visits, treatment goals and objective measure to evaluate treatment effectiveness The primary diagnosis documented must be subluxation, including the level of subluxation, either so stated or identified by one of the following descriptive terms for the nature of the abnormalities: Off-centered Misalignment Malpositioning Spacing---abnormal, altered, decreased, increased Incomplete dislocation Rotation Listhesis---antero, postero, retro, lateral, spondylo Motion-limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant There are two ways in which the level of subluxation may be specified. The exact bones may be listed (e.g., C5, C6) The area may suffice if it implies only certain bones such as: occipito-atlantal (Occiput and C1 (atlas)), lumbo-sacral (L5 and sacrum), and sacro-iliac (sacrum and ilium) Area of SpineNames of VertebraeNumber of VertebraeShort form or Other name NeckOcciput7Occ, CO CervicalC1 thru C7 AtlasC1 AxisC2 BackDorsal or12D1 thru D2 ThoracicT1 thru T12 CostovertebralR1 thru R12 CostotransverseR1 thru R12 Low BackLumbar5L1 thru L5 PelvisIIii, r and 1I, Si SacralSacrum, CoccyxS, SC The chiropractor must document in the medical record the treatment phase or month of treatment for the services provided. In addition, it should be documented in the individual's medical record whether the individual has had an exacerbation (flare up while being treated) or recurrence (recurring after 90 days or more of no treatments) of a previously treated acute condition. Guidelines This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare. BENEFIT APPLICATIONSubject to the terms and conditions of the applicable Evidence of Coverage, chiropractic services are covered under the medical benefits of the Company’s Medicare Advantage products when the coverage criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.Additional chiropractic manipulation services may be available based on the member's evidence of coverage. Description According to Medicare, chiropractic services are performed through the means of manual manipulation (i.e., by use of the hands) of the spine. DEFINITIONS Chiropractic (therapeutic) manipulation, commonly referred to as spinal and extraspinal adjustment, manual adjustment, vertebral adjustment, or spinal manipulative therapy (SMT), is the treatment of the articulations of the spine and musculoskeletal structures, including the extremities, for the purpose of relieving discomfort resulting from impingement of associated nerves or other structures (e.g., joints, tissues, muscles). In spinal manipulation, manual or mechanical means may be used to correct a structural imbalance or subluxation related to distortion or misalignment of the vertebral column. Subluxation is an alteration in alignment, movement integrity, and/or physiologic function of the spine in which contact between the surfaces of the joints remains intact. Subluxation may be acute or chronic. Acute subluxation is defined as a new injury, identified by X-ray or physical exam in which the result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the individual's condition. Chronic subluxation is defined as an existing injury that is not expected to significantly improve or be resolved with further treatment but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, ongoing manipulation is considered maintenance therapy.Extraspinal manipulation, also known as extraspinal manipulative therapy (EMT), is used to treat joint dysfunction outside of the vertebral column. Extraspinal regions are the following: head (excluding atlanto-occipital. including temporomandibular joint), Lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral joints), and abdomen. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or as a therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. References Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. §240: Chiropractic Services. [CMS Web site]. 07/12/19. Available at: http://www.cms.gov/media/125221. Accessed December 5, 2019.Centers for Medicare & Medicaid Services.(CMS) Misinformation on Chiropractic Services. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1601.pdf. Accessed December 5, 2019.Novitas Solutions Inc. Local Coverage Article(A52987). Chiropractic Services [Novitas Solutions Web site]. Original 10/01/2015. Revised 03/27/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52987&ver=17&Date=12/05/2019&SearchType=Advanced&ContrId=&DocID=A52987&bc=JAAAABgAAAAA&. Accessed December 5, 2019.Novitas Solutions Inc. Local Coverage Determination.(LCD) L35424. Chiropractic Services.[Novitas Solutions Web site] Original 10/01/2015. (Revised: 03/27/2019). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35424&ver=38&Date=12/05/2019&SearchType=Advanced&DocID=L35424&search_id=&service_date=&bc=KAAAABgAAAAA&. Accessed December 5, 2019. Coding CPT Procedure Code Number(s) COVERED 98940, 98941, 98942 NONCOVERED98943 ICD - 10 Procedure Code Number(s) N/A ICD - 10 Diagnosis Code Number(s) ​See Attachment A. HCPCS Level II Code Number(s) NOT COVEREDS8990 Physical or manipulative therapy performed for maintenance rather than restoration Revenue Code Number(s) N/A Modifiers AT Acute treatment Coding and Billing Requirements BILLING REQUIREMENTSClaims submitted for chiropractic services (CPT codes 98940, 98941, or 98942) must include ALL of the following and are subject to the limitations outlined in this policy: A primary diagnosis code representing segmental and somatic dysfunction (International Classification of Disease [ICD] ICD-10 diagnosis codes (M99.00, M99.01, M99.02, M99.03, M99.04, M99.05). A secondary diagnosis code from one of the diagnosis groups A, B, C, or D which are listed within attachment A of this policy. The acute treatment (AT) modifier. Policy History MA10.004h10/01/2021The version of this policy will become effective 10/01/2021.  The following ICD-10 CM code has been termed from Attachment A of this policy: M54.5: Low back pain The following ICD-10 CM codes have been added to Attachment A of this policy as Medically Necessary: M54.50: Low back pain, unspecified M54.51: Vertebrogenic low back pain M54.59: Other low back pain​Revisions From MA10.004g:06/02/2021The policy has been reviewed and reissued to communicate the Company's continuing position on ​Chriropractic Services.​​10/01/2020​This policy had been identified for the ICD-10 CM update effective 10/01/2020.The following ICD-10 CM code has been added to Attachment A of this policy:​R51.9: Headache, unspecifiedThe following ICD-10 CM code had been termed from Attachment A of this policy:R51:​  HeadacheRevisions From MA10.004f: 05/18/2020The version of this policy will become effective 05/18/2020. The intent of this policy has not changed, although it has been updated to further define spinal manipulation and subluxation. The following HCPCS code has been added to the policy: S8990. The following ICD-10 diagnosis codes have been removed from the policy: M79.10, M79.11, M50.120, M50.820, M50.920, M50.220, M50.320, M99.62, M99.63, M99.72, M99.73, Q76.2, S13.100A, S13.100D, S13.100S, S13.101A, S13.101D, S13.101S, S13.110A, S13.110D, S13.110S, S13.111A, S13.111D, S13.111S, S13.120A, S13.120D, S13.120S, S13.121A, S13.121D, S13.121S, S13.130A, S13.130D, S13.130S, S13.131A, S13.131D, S13.131S, S13.140A, S13.140D, S13.140S, S13.141A,S13.141D, S13.141S, S13.150A, S13.150D, S13.150S, S13.151A, S13.151D, S13.151S, S13.160A, S13.160D, S13.160S, S13.161A, S13.161D, S13.161S, S13.170A, S13.170D, S13.170S, S13.171A, S13.171D, S13.171S, S13.180A, S13.180D, S13.180S, S13.181A, S13.181D,S13.181S, S14.2XXA, S14.2XXD, S14.2XXS, S14.3XXA, S14.3XXD, S14.3XXS, S23.0XXA, S23.0XXD, S23.0XXS, S23.100A, S23.100D, S23.100S, S23.101A, S23.101D, S23.101S, S23.110A, S23.110D, S23.110S, S23.111A, S23.111D, S23.111S, S23.120A, S23.120D, S23.120S, S23.121A, S23,121D, S23.121S, S23.122A,S23.122D, S23.122S, S23.123A, S23.123D, S23.123S, S23.130A, S23.130D,S23.130S, S23.131A, S23.131D, S23.131S, S23.132A, S23.132D, S23.132S, S23.133A, S23.133D, S23.133S, S23.140A, S23.140D, S23.140S, S23.141A, S23.141D, S23.141S, S23.142A, S23.142D, S23.142S, S23.143A, S23.143D, S23.143S, S23.150A, S23.150D,S23.150S, S23.151A, S23.151D, S23.151S, S23.152A, S23.152D, S23.152S, S23.153A, S23.153D, S23.153S, S23.160A, S23.160D, S23.160S, S23.161A, S23.161D, S23.161S, S23.162A, S23.162D, S23.162S, S23.163A, S23.163D, S23.163S, S23.170A, S23.170D, S23.170S, S23.171A, S23.171D, S23.171S, S24.2XXA, S24.2XXD, S24.2XXS, S33.0XXA, S33,0XXD, S33.0XXS, S33.100A, S33.100D, S33.100S, S33.101A, S33.101D, S33.101S, S33.110A, S33.110D, S33.110S, S33.111A, S33.111D, S33.111S, S33.120A, S33.120D, S33.120S, S33.121A,S33.121D, S33.121S, S33.130A, S33.130D, S33.130S, S33.131A, S33.131D, S33.131S, S33.140A, S33.140D, S33.140S, S33.141A, S33.141D, S33.141S, S33.2XXA, S33.2XXD, S33.2XXS, S34.21XA, S34.21XD, S34.21XS, S34.22XA, S34.22XD, S34.22XS, S34.4XXA, S34.4XXD, S34.4XXS. Revisions From MA10.004e: 10/01/2018This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy: M79.10, M79.11, M79.12, M79.18. The following ICD-10 code have been termed from the policy: M79.1. Revisions From MA10.004d: 08/01/2018As of 8/01/2018, this policy has been reissued in accordance with the Company's annual review process. 10/01/2017This version of the policy will become effective 10/01/2017. The following ICD-10 CM codes have been added to this policy: (medically necessary) M48.061 Spinal stenosis, lumbar region without neurogenic claudication M48.062 Spinal stenosis, lumbar region with neurogenic claudication The following ICD-10 CM code has been termed from this policy: M48.06 Spinal stenosis, lumbar region Revisions From MA10.004c: 06/07/2017This policy has been reissued in accordance with the Company's annual review process. 12/21/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Chiropractic Services. 10/01/2016This version of the policy will become effective 10/01/2016. The following ICD-10 Diagnosis codes have been deleted from this policy: M50.12, M50.22, M50.32, M50.82, M50.92 The following ICD-10 Diagnosis codes have been added to this policy: M50.120, M50.121, M50.122, M50.123, M50.220, M50.221, M50.222, M50.223, M50.320, M50.321, M50.322, M50.323, M50.820, M50.821, M50.822, M50.823, M50.920, M50.921, M50.922, M50.923 Revisions From MA10.004b: 12/30/2015This version of the policy will become effective 12/30/2015. The intent of this policy remains unchanged. Benefit application language has been updated. Revisions From MA10.004a: 08/12/2015Revised medical policy MA10.004a will become effective 08/12/2015. Clarifying language has been added to the "Limitations" section of the policy section and ICD-10 codes have been added to the policy. 06/29/2015Current medical policy MA10.004a became effective 01/01/2015. Policy was revised to provide clarification of policy and medical necessity criteria for acute subluxation. Revisions From MA10.004: 01/01/2015This is a new policy. Version Effective Date: 10/1/2021 Version Issued Date: 10/1/2021 Version Reissued Date:

Chiropractic Services. Policy In accordance with the Centers for Medicare & Medicaid Services (CMS), chiropractic services are covered when both the established coverage criteria and the Medical Necessity criteria, listed in this policy, are met.Chiropractic services performed by means of manual manipulation (i.e., by use of the hands) of the spine are covered for the purpose of correcting a confirmed acute subluxation as a result of a new injury demonstrated by x-ray or physical examination.. Chiropractic spinal manipulation services are additionally covered for one of the following conditions and must be clearly documented and reflective of the individual’s symptoms and treatment history:. Chiropractic spinal manipulation treatments must be reported with a primary diagnosis code representing an acute subluxation as well as the acute treatment (AT) modifier.. Treatment for chronic subluxation and maintenance therapy are not covered by the Company because these services are not covered by Medicare.. In accordance with Medicare, chiropractic maintenance therapy is considered not covered.. However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.. 06/02/2021The. policy has been reviewed and reissued to communicate the Company's continuing. position on ​Chriropractic Services.​​10/01/2020​This policy had been identified for the ICD-10 CM update effective 10/01/2020.The following ICD-10 CMcode has been added to Attachment A of this policy:​R51.9: Headache, unspecified. Revisions From MA10.004f: 05/18/2020The version of this policy will become effective 05/18/2020.The intent of this policy has not changed, although it has been updated to further define spinal manipulation and subluxation.The following HCPCS code has been added to the policy: S8990.The following ICD-10 diagnosis codes have been removed from the policy: M79.10, M79.11, M50.120, M50.820, M50.920, M50.220, M50.320, M99.62, M99.63, M99.72, M99.73, Q76.2, S13.100A, S13.100D, S13.100S, S13.101A, S13.101D, S13.101S, S13.110A, S13.110D, S13.110S, S13.111A, S13.111D, S13.111S, S13.120A, S13.120D, S13.120S, S13.121A, S13.121D, S13.121S, S13.130A, S13.130D, S13.130S, S13.131A, S13.131D, S13.131S, S13.140A, S13.140D, S13.140S, S13.141A,S13.141D, S13.141S, S13.150A, S13.150D, S13.150S, S13.151A, S13.151D, S13.151S, S13.160A, S13.160D, S13.160S, S13.161A, S13.161D, S13.161S, S13.170A, S13.170D, S13.170S, S13.171A, S13.171D, S13.171S, S13.180A, S13.180D, S13.180S, S13.181A, S13.181D,S13.181S, S14.2XXA, S14.2XXD, S14.2XXS, S14.3XXA, S14.3XXD, S14.3XXS, S23.0XXA, S23.0XXD, S23.0XXS, S23.100A, S23.100D, S23.100S, S23.101A, S23.101D, S23.101S, S23.110A, S23.110D, S23.110S, S23.111A, S23.111D, S23.111S, S23.120A, S23.120D, S23.120S, S23.121A, S23,121D, S23.121S, S23.122A,S23.122D, S23.122S, S23.123A, S23.123D, S23.123S, S23.130A, S23.130D,S23.130S, S23.131A, S23.131D, S23.131S, S23.132A, S23.132D, S23.132S, S23.133A, S23.133D, S23.133S, S23.140A, S23.140D, S23.140S, S23.141A, S23.141D, S23.141S, S23.142A, S23.142D, S23.142S, S23.143A, S23.143D, S23.143S, S23.150A, S23.150D,S23.150S, S23.151A, S23.151D, S23.151S, S23.152A, S23.152D, S23.152S, S23.153A, S23.153D, S23.153S, S23.160A, S23.160D, S23.160S, S23.161A, S23.161D, S23.161S, S23.162A, S23.162D, S23.162S, S23.163A, S23.163D, S23.163S, S23.170A, S23.170D, S23.170S, S23.171A, S23.171D, S23.171S, S24.2XXA, S24.2XXD, S24.2XXS, S33.0XXA, S33,0XXD, S33.0XXS, S33.100A, S33.100D, S33.100S, S33.101A, S33.101D, S33.101S, S33.110A, S33.110D, S33.110S, S33.111A, S33.111D, S33.111S, S33.120A, S33.120D, S33.120S, S33.121A,S33.121D, S33.121S, S33.130A, S33.130D, S33.130S, S33.131A, S33.131D, S33.131S, S33.140A, S33.140D, S33.140S, S33.141A, S33.141D, S33.141S, S33.2XXA, S33.2XXD, S33.2XXS, S34.21XA, S34.21XD, S34.21XS, S34.22XA, S34.22XD, S34.22XS, S34.4XXA, S34.4XXD, S34.4XXS.. The following ICD-10 codes have been added to the policy: M79.10, M79.11, M79.12, M79.18.. The following ICD-10 code have been termed from the policy: M79.1.. The followingICD-10 Diagnosis codes havebeen deleted from this policy: M50.12, M50.22, M50.32, M50.82, M50.92The following ICD-10 Diagnosis codes havebeen added to this policy:M50.120, M50.121, M50.122, M50.123, M50.220, M50.221, M50.222, M50.223, M50.320, M50.321, M50.322, M50.323, M50.820, M50.821, M50.822, M50.823, M50.920, M50.921, M50.922, M50.923 Revisions From MA10.004b: 12/30/2015This version of the policy will become effective 12/30/2015.The intent of this policy remains unchanged.

Chiropractic billing & coding expert Dr. Tom Necela of The Strategic Chiropractor explains how to handle problems with CPT Code 98943 for Chiropractors - along with why the problems exist in the first place.

It is with sadness that I report at the problems with CPT code 98943 (for a chiropractic extremity adjustment) have continued for well over 5 years now and it does not look like that the challenges will be disappearing anytime soon.. Unfortunately, we routinely get emails from confused chiropractors and their staff regarding problems they are having while wrestling with payers over getting CPT code 98943 paid.. In my opinion, the first challenge with 98943 stems from the fact that it is essentially a code used only by chiropractors.. The first problem that many chiropractor saw was that there 98943 extra spinal adjustment was bundled in with the other adjustment services they provided (98940, 98941 or 98942).. At the least, this obviously does not apply to chiropractic adjustment coding and worse, it can actually cause problems as we addressed in a previous post on CPT code 98943 .. That event should have signaled the end of problems chiropractors had with CPT code 98943, but unfortunately the chaos continued up until 2015, when a new problem emerged.. Here are the simple facts about Modifier 59 (and its replacements) and the source of some confusion.. But since it is an adjustment to an extraspinal area, as opposed to the other chiropractic adjustment codes that apply to spinal manipulations, it’s my opinion that the modifier 59 should not be necessary based on the “not normally reported” together rationale.. From another angle, modifier 59 is also used to indicate separate and distinct services that do not overlap when the practitioner is performing timed codes.. While that angle makes sense from a general coding perspective, it does not really apply to problems with CPT code 98943, because neither the extremity adjustments nor spinal adjustments (98940, 98941 or 98942) are timed.. If a payer refuses to pay because of bundling, you must appeal the claim and reference that these are separately payable codes from your chiropractic spinal adjustments.. Moving onward, if a payer attempts to bundle your payment insists on Modifier 51, use the above citation from the CPT Assistant to refute their nonsense.

CPT Code Description 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions

CPT Code Description98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions. 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions. 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions (Not Covered) INTRODUCTION TO CHIROPRACTIC SERVICES. HCPCS CODES 98940© Chiropractic manipulation. 98941© Chiropractic manipulation. 98942© Chiropractic manipulation. 98943© Chiropractic manipulation. Documentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT).. Documentation must support that manipulative treatment occurred in three to four regions of the spine (region as defined by CPT) and one of the following:. 1. validated diagnoses for three or four spinal regions. 2. validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings. Documentation must support that manipulative treatment occurred in five regions of the spine (region as defined by CPT) and one of the following:. 1. validated diagnoses for five spinal regions. 2. validated diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings. 3. validated diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings. 98943 Chiropractic manipulative treatment (CMT); extraspinal, one to five regions Documentation must support that manipulative treatment occurred in one or more extraspinal regions (as defined by CPT), and there is a validated diagnosis for one or more extraspinal regions for which manipulation has been shown to be both safe and efficacious per appropriate Optum medical policy.. Modifier -51 (Multiple Procedures) is not required to be appended to the extraspinal CMT procedural code (98943), when billed on the same date of service as a spinal CMT code (98940-98942).. CPT describes the application of modifier -25 when E/M services are reported in conjunction with CMT procedural codes (98940- 98943), “The chiropractic manipulative treatment codes include a pre-manipulation patient assessment.. Modifier -51 ( Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940- 98943).. These E/M services may be billed in addition to the chiropractic manipulative treatment (98940-98942) ONLY when the patient has not received any professional (face-to-face) services from the chiropractor, or another chiropractor of the same group practice, within the past three years.. Moda Health does not apply multiple procedure fee reductions to Osteopathic Manipulative Treatment (OMT) procedures or Chiropractic Manipulative Treatment (CMT) procedures.

Since CPT Code 98943 (which is chiropractic adjustment to the extremities) is a procedure performed by exclusively by chiropractors, there seems to be some misunderstandings and misinterpretation of proper coding rules when it comes to getting paid. This certainly is not a one-sided problem. Both chiropractors and insurance payers appear to be missing the mark […]

Since CPT Code 98943 (which is chiropractic adjustment to the extremities) is a procedure performed by exclusively by chiropractors, there seems to be some misunderstandings and misinterpretation of proper coding rules when it comes to getting paid.. While it is true that Medicare does not reimburse CPT code 98943, most other payers do.. This does not apply to chiropractic adjustment coding.. Finally, according to CPT Assistant December 2013 issue, “these are separate and distinct procedures, and the use of Modifier -51 (Multiple Procedures) does not apply.. In other words, you can also use Modifier 59 (or its replacements) to communicate to the payer that the timed service you provided was done in addition to the other timed services you also performed on that date – and you want to be paid for both.. The above situations are the most common problems chiropractors encounter when billing 98943 extraspinal adjustments, so you should now be able to navigate this code to get you paid for the good work that you do!

Videos

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3. HJ Ross Company Chiropractic Insurance Billing and Coding App
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4. Target Coding Modifiers 3
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