FAQs About Medicare Coverage of Chiropractic Services

In the Medicare Learning Network booklet on chiropractic services (pdf), CMS addresses more than a dozen of the most frequently asked questions about Medicare coverage of chiropractic services.

These questions — and the responses provided by CMS — are as follows:

Q: Are there any visit caps or limits for chiropractic services?

A: No. There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare's licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5 (available at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html). There may be review screens (numbers of visits at which the Medicare Carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.

Q: Do non-participating (non-par) providers of chiropractic services have to bill Medicare for services to Medicare beneficiaries?

A: Yes. Being non-par does not mean the provider doesn't have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties. For more details on participating and non-par providers, see the fact sheet entitled "Medicare Enrollment for Physicians, Non-Physician Practitioners, and Other Health Care Suppliers" at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/suppliers.pdf (pdf).

Q: Is it true that non-par providers are not subject to Medicare audits/ reviews?

A: No. The non-par or participating (par) status of the physicians does not affect the possibility of any of their Medicare claims being audited/reviewed. CMS audits/reviews are intended to protect Medicare trust funds and to identify billing errors so providers and their billing staff can be alerted to errors and educated on how to avoid future errors.

Q: Can chiropractors opt out of Medicare?

A: No. Opting out of Medicare is not an option for Doctors of Chiropractic. Being non-participating and opting out are not the same things. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out.

For further discussions of the Medicare "opt out" provision, see the Medicare Benefit Policy Manual (Chapter 15, Section 40; Definition of Physician/ Practitioner) at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf (pdf).

Q: Can chiropractors (specialty 35) ever bill for durable medical equipment, prosthetics, orthotics, and supplies?

A: Yes. If as the supplier, they have a valid supplier number assigned by the National Supplier Clearinghouse and Medicare's rules for ordering the supplies are followed. However, a chiropractor who is a supplier cannot both order and furnish the DME. If a chiropractor orders DME, it will not be reimbursed.

Q: Under what circumstances should the chiropractor get an advance beneficiary notice (ABN) signed by the patient?

A: 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, the chiropractor must submit a claim to Medicare even though it is expected that Medicare will deny the claim and that the beneficiary will pay, unless the beneficiary selects option 2 on the ABN.

Q: What are the covered chiropractic services under Medicare?

A: Spinal manipulation is a covered service under Medicare. Acute, chronic, and maintenance adjustments are all "covered" services, but only acute and chronic services are considered active care and therefore, may be reimbursable. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment moves from corrective to supportive in nature, the treatment is then considered maintenance therapy.

Q: Do non-par providers have the same documentation requirements as par providers?

A: Yes. Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is not relevant to the documentation requirements.

Q: How does Medicare define subluxation?

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 services remains intact.

A subluxation may be demonstrated by an x-ray or by a physical examination.

Q: Are maintenance therapy services covered by Medicare?

A: Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable.

Q: How does Medicare define maintenance therapy services?

A: 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.

Q: How should a chiropractor bill for maintenance services?

A: 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.

Q: How can a subluxation be demonstrated?

A: A subluxation may be demonstrated by an x-ray or by physical examination.

Q: Are chiropractors eligible for bonus incentive programs?

A: Doctors of Chiropractic are eligible for the eRx Incentive Program and the Physician Quality Reporting Initiative (PQRI) additional payments. Chiropractors are not eligible for incentive payments for Physician Scarcity Area payments.

Q: What expenses for chiropractic services is the beneficiary responsible for in 2013?

A: In 2013, for approved Part B services, the beneficiary will pay the Part B deductible and then 20% of the Medicare-approved amount. The beneficiary will also pay all costs for any non-covered services. Beneficiary cost-sharing for Part C (Medicare Advantage) services will vary according to plan benefits.

Q: What needs to be done to have a claim considered for Medicare Secondary Payer benefits?

A: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form. (See Medicare Secondary Payer Manual, Chapter 3).

Q: Do I have to submit a claim to Medicare if the beneficiary agrees to pay for the service?

A: Remember that, no matter what the beneficiary is willing to agree to, you have fee restrictions in place and Mandatory Claim Submission still applies. The only exception to this would be if the beneficiary specifically requests that you NOT bill Medicare. In that instance, you would NOT submit a claim, but the fee restrictions would still apply.

Q: Do I have to submit a claim to Medicare, even though I know the service will be denied and the beneficiary has agreed to pay?

A: This is one of the purposes of the ABN. If you have a covered service you feel will be denied, you would present an ABN to the beneficiary. If they choose Option #1, yes, you would still be required to submit a claim. If the beneficiary chooses Option #2, then you would not be able to submit a claim.

Note: The responses provided by CMS were current as of October 2013. Medicare policy changes frequently, so ensure you are properly following Medicare chiropractic billing and coding rules prior to submitting claims.

Have questions about performing proper chiropractic billing and coding? Contact PGM Billing, one of the country's leading chiropractic billing companies, to learn what they can do for your practice.


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