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Chiropractic Manipulative Treatments

The following link is to a previously published article in June 2006 reviewing the errors found from the chiropractic reviews being done at that time.

Presently (summer 2007), chiropractic reviews continue to find the same errors; and, therefore, we are republishing this article in effort to reduce the error rate in Medicare payments for spinal manipulation. We particularly want to emphasize the following points:

  • History and assessment are essential parts of each encounter for spinal manipulation. This information should be part of the documentation of a complete episode of care in the medical record beginning with a plan of treatment established on the initial visit that supports the medical necessity of spinal manipulation.
  • Many providers fail to have a complete or any plan of treatment which should include the elements detailed in the article below.
  • Conspicuously absent in many records have been patient- individualized goals expressed in measurable terms. These goals should be referenced on subsequent encounters in the assessment to measure the patient's progress and support the ongoing need of spinal manipulation (versus the patient having reached maximum long-term improvement and care would now be maintenance which is not covered by Medicare).
  • Also missing from plans of treatment have been a frequency and expected duration of care. These should represent a reasonable expectation of recovery or functional improvement measured by the patient's goals.
  • The area being treated should involve a subluxation that would be directly related to the patient's complaint. For example, if the patient's complaint was low back pain, manipulation of the cervical spine would not be warranted.
  • Subluxation must be supported by either an x-ray or physical exam.
    • If subluxation is established by physical exam, the findings must include either asymmetry or range of motion abnormality at a sectional/segmental level in addition to pain/tenderness and/or tissue tone changes at associated or contiguous soft tissues.
  • Levels treated should be clearly documented to support code billed.
  • Spinal manipulation codes should only be billed for manual manipulation techniques and not for any other techniques excluded from coverage by Medicare including for example:
    • Non-manipulative treatments such as massage
    • Infrared light and/or heat treatments
    • Spinal decompression tables

The noncoverage of the last two of the above are respectively specified in the following national coverage decisions:

Progressive Corrective Action on Chiropractic Manipulative Treatments

The CERT program continues to find errors on review of randomly selected chiropractic services that have been paid by Medicare. These errors have prompted a probe of chiropractic services in Idaho by CGS. Previously, chiropractic manipulations were the focus of another CGS probe in 2004. This most recent probe involved approximately 100 claims from 20 chiropractors. The results of this probe validated the random CERT review findings in that errors were present on a greater scale within the larger provider specialty community. The errors identified in this probe reflected many of the findings noted in the earlier (2004) probe. This article is intended to detail these errors so that providers in all the states that CGS serves can make corrections within their own practices if needed. This would assist providers in avoiding post-payment review errors and the range of progressive corrective actions implemented by the carrier or other entities in effort to resolve any inappropriate Medicare payments. These progressive corrective actions could include recoupment of any identified overpayments, ongoing intermittent requests of records for review, pre-payment "screens" that require review of any future claims and the corresponding supporting documentation before any payment made, and/or referral to the Benefit Integrity contractor.

The errors found can be outlined as follows:

  • Insufficient initial visit documentation
    • history lacking detail of symptoms
    • exam--especially on manually demonstrated subluxation**
  • Absent or incomplete treatment plans
    • no measurable goals
    • no frequency & duration of treatment
    • specific levels being treated and/or modalities not present
  • Subsequent visits fail to establish medical necessity for ongoing care
    • no assessment of progress since previous visit
    • no assessment against goals from plan of treatment
    • use of flow sheets/checklists that document treatment rendered but do not address or include an assessment or improvement expected on subsequent visits
    • subsequent visits appear to be for maintenance therapy which is not covered by Medicare
  • Coding errors
    • the level of code billed was not supported by # of regions treated as documented in the medical record
    • notes did not indicate specific levels of subluxation being treated or
    • service rendered was not manual manipulation (which is the only service payable by Medicare to chiropractors)
  • Illegible notes

Expected on the initial visit is a thorough history that details the symptoms prompting the patient to seek treatment. Other elements of the history expected to be included are, for example, the onset, duration, location and radiation of symptoms. The following link is to a previously published article itemizing all of the elements that should be included in the history: http://www.cgsmedicare.com/partb/pubs/mb/2004/04_11/base_november11.html#007

Also required on the initial visit is the diagnosis of subluxation that corresponds to the symptoms the patient demonstrates. In other words, these symptoms must bear a direct relationship to the level of subluxation. The diagnosis of subluxation can be made either by a dated x-ray with results or by a physical exam noting 2** of the 4 following criteria to support a manually demonstrated subluxation:

  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 a decrease of sectional or segmental mobility)
  4. Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle and ligament.

**One of the two criteria documented must be either asymmetry or range of motion abnormality.

A treatment plan should also be generated at the initial visit, and it should include the goals expressed in measurable terms. Besides these goals, the treatment plan should detail the frequency, duration and projected end-point of the therapy. The use of "PRN" or "as needed" for a frequency of treatment does not establish the treatment as medically necessary for an acute condition and suggests treatment is for maintenance of a chronic condition.

Each subsequent visit should update the patient's history, exam and progress toward the treatment plan. This would then help substantiate ongoing care based on any changes in the patient's signs and symptoms, physical findings, response to treatment and any modifications to the treatment plan.

Once the patient's condition has been stabilized, treatment is no longer a Medicare benefit. This would apply even if each treatment of a chronic condition resulted in some temporary improvement. If there is no substantial long-term improvement, this would be considered "chronic maintenance" treatment and not payable by Medicare nor would it qualify the service for billing using the AT modifier. In our probe reviews, we did find some patients who were into their 4th year of ongoing chiropractic manipulation without evidence of re-injury or exacerbation. This would appear to be maintenance and should have not been billed to Medicare as a covered service.

Finally, spinal manipulation codes differ according to the number of regions treated. Therefore, the record should identify for each encounter the exact regions treated and that support the code billed. Additionally, spinal manipulation codes cannot be billed for any other service that is not spinal manipulation.

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