Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27480

Chiropractic Services

L27480

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

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual, Pub. 100-2, Chapter 15, Section 30.5

CMS Online Manual, Pub. 100-2, Chapter 15, Section 240

CMS Online Manual, Pub. 100-2, Chapter 15, Section 240.1

CMS Online Manual, Pub. 100-4, Chapter 17, Section 60.1

Transmittal B-01-58, Change Request 1820

Transmittal 1805, Change Request 2717

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation (i.e., by use of hands) of the spine, for the purpose of correcting a subluxation. For the purpose of Medicare, a 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.

No other diagnostic or therapeutic service furnished by a chiropractor or under his or her order is covered. This means that if a chiropractor orders, takes, or interprets an X-ray, or any other diagnostic test, the X-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. 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 covered when it is ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy. Chiropractors can refer patients to doctors of medicine or osteopathy for diagnostic evaluation and/or testing.

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:

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

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 a chiropractor 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.

Indications

The patient must have a significant health problem in the form of a neuro-musculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectations 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 may be categorized as follows:

• 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.

It must be clear in the patient's medical record in which category the patient falls (acute or chronic subluxation), and all the requirements addressed in the "Documentation Requirements" section of this policy must be recorded in the patient's medical record and be available to the contractor upon request.

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.

The chiropractor must also indicate the treatment phase or month of treatment for the services provided. In addition, it should be documented in the patient's medical record whether the patient has had an exacerbation (flare up while being treated) or recurrence (recurring after 30 days or more of no treatments) of a previous condition. Medicare covers additional manipulations when an exacerbation or recurrence occurs. This must clearly be documented and reflective of the patient's presenting symptomatology and treatment history.

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:

There are two ways in which the level of subluxation may be specified.

1. The exact bones may be listed, for example: C5, C6, etc.
2. 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).

   Note:

   The following are some common examples of acceptable terms that may be used to describe 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). Other terms may be used and are acceptable when they are understood clearly to refer to the bone or joint space or position (or motion) changes of vertebral elements.

Limitations

1. Maintenance Therapy

   Under the Medicare program, chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or 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. 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.

2. 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.

Chiropractic Services

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

When the service has been provided for a diagnosis that is not listed in the "Covered Secondary ICD-9 codes" section of this policy, the provider must thoroughly document the medical necessity and rationale for providing the service for the unlisted diagnosis in the patient's medical record.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.

Documentation of a subluxation may be demonstrated by an X-ray or by a physical examination. All levels of subluxation identified must be documented in the patients' medical record, regardless of the current treatment plan.

1. Demonstrated by X-ray: An X-ray may be used to document a subluxation but is not required. 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. (For more specific information on the coverage/noncoverage guidelines of chronic conditions and maintenance therapy see the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy). A previous CT scan and/or MRI of the spine may be used, in lieu of an X-ray, when a subluxation of the spine is demonstrated. The time frames specified for X-rays are also applicable for MRIs and CT scans.
2. Demonstrated by Physical Examination: A physical examination may be used to document a subluxation. Evaluation of musculoskeletal/nervous system to identify:

   (P) Pain/tenderness evaluated in terms of location, quality, and intensity;

   (A) Asymmetry/misalignment identified on a sectional or segmental level;

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

   (T) 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 the "Demonstrated by Physical Examination" section of this policy are required, one of which must be asymmetry/misalignment or range of motion abnormality.

   The history recorded in the patient's medical 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.

In addition to the above documentation requirements the following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination:

For the Initial Visit:

1. History as stated above;
2. Description of the present illness including:
   • 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.
   • 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 (it is), 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 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.
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.

For Subsequent Visits:

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

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

If a national or local policy identifies a frequency expectation, a claim for a test/service that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency.

Chapman-Smith D., The Chiropractic Profession; Copyright 2000 NCMIC Group Inc.

Current Procedural Terminology (CPT) 2000; American Medical Association; Copyright 1999

Haldeman S., Chapman-Smith D., Petersen Jr., D.M., Guidelines for Chiropractic Quality Assurance and Practice Parameters; An Aspen Publication, Copyright 1993.

Medicare's National Level II Codes, HCPCS, 2000; American Medical Association; 12th Edition; Copyright 1999

Medicode's International Classification of Diseases, 9th Revision, Clinical Modification, Copyright 1998

Carrier Medical Directors' Chiropractic Clinical Workgroup

Other Contractor's policies

Highmark Medicare Services Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups that include representatives from the Chiropractic specialty.

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27480

05/22/2008

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