Active/Corrective vs Maintenance

Contrary to popular belief, there are no caps/limits for covered chiropractic care. There may be review screens (numbers of visits at which the Medicare carrier may require a review of documentation), but caps/limits are not allowed.

The Social Security Act provides that Medicare will only pay for items or services it determines to be “reasonable and necessary,” and if those items or services can be shown to be reasonable and necessary, then those items or services are covered and will be paid by Medicare.

In short, your documentation (histories, examinations, diagnosis and SOAP notes) must support medical necessity for your adjustments to be covered.

Active/Corrective 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 xray or physical examination.

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.

You must place the 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.

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.

You should consider providing the Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary. Chiropractors who give beneficiaries an ABN will place the modifier GA (or in rare instances modifier GZ) on the claim. 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. If the beneficiary decides to receive the service, you must submit a claim to Medicare even though you expect that Medicare will deny the claim and that the beneficiary will pay.

For additional information regarding maintenance therapy, refer to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30.5.

You may want to consider our Medicare ABN course.

Take a look at our complete Chiropractic Medicare Course