Overview of Medicare Policy Regarding Chiropractic Services

Medicare Learning Network (MLN) document SE1101 highlights Medicare policy regarding coverage of chiropractic services for Medicare beneficiaries. This article was revised on September 9, 2011, to clarify some of the language. No changes in policy are conveyed by these clarifications.

The “Key Points” section reviews Medicare policy for coverage of chiropractic services and emphasizes the billing and documentation requirements.

The following key points are discussed in detail:

• Medicare coverage of chiropractic services.
• Subluxation may be demonstrated by X-ray or physician’s examination.
• Documentation requirements must be placed in the patient’s file.
• Necessity for treatment.
• Key billing requirements.
• Beneficiary responsibility.

The Background Section of the MLN document is included here. Click here to view the complete article, including the Key Points.

Background

Numerous audits of chiropractic service claims have found a significant portion of the claims to have been paid inappropriately. Correct claim payment depends largely on providers complying with Medicare requirements for coverage, coding, and documentation of services. The goal of this article is to translate published Medicare coverage and payment requirements for chiropractic services into a few practical tips for better Medicare compliance to effectively lower the frequency of improper payments (and corresponding error rates).

The most common errors noted by Medicare auditors of chiropractic service claims are briefly described below.

• Technical errors such as missing signatures, date of service on the claim not found in the record, etc. In other words, specific documentation that is required as a condition of payment is often missing from the beneficiary’s medical record.
• Documentation that does not substantiate that all procedure(s) reported were performed. For example,
  • No documentation or insufficient documentation that all spinal levels of manipulation reported had been performed;
  • No documentation that each manipulation reported related to a relevant symptomatic spinal level.
• Insufficient or absent documentation that all procedures or services were medically reasonable and necessary. In other words, the submitted documentation was not sufficient for Medicare auditors to determine whether the services furnished were medically necessary. Examples of insufficient or absent documentation for purposes of determining medical necessity are as follows: 
  • Required elements of the history and examination were absent.
  • Treatment plan absent or insufficient.
• Treatment furnished was “maintenance therapy. As discussed later in this article, Medicare pays only for medically necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. When further improvement cannot reasonably be expected from continuing care, the services are considered maintenance therapy, which is not medically necessary and therefore not a covered service under the Medicare program.
  
• Non-Covered devices or techniques applied in performing manipulation. (See the key points section of this article.)

Previous Study by the Office of Inspector General (OIG) on Chiropractic Care

A recent study by the Office of Inspector General (OIG) entitled “Inappropriate Medicare Payments for Chiropractic Services” found inappropriate Medicare payments for chiropractic services.

The OIG study found that:

• Claims lack initial visit dates for treatment episodes, hindering the identification of maintenance therapy; and
• There is lack of compliance with the manual documentation requirements. For example, treatment plans, an important element in determining whether the chiropractic treatment was active/corrective in achieving specified goals, were either missing or lacked treatment goals, objective measures, or the recommended level of care.

The Key Points section below reviews Medicare policy for coverage of chiropractic services, with an emphasis on the billing and documentation requirements.