Medicare Coverage For Chiropractic Care and Deductible Periods

How does Medicare work with chiropractic care?

Numerous misunderstanding of charges for the $100 deductible are not sent to the Medicare, and that the $100 can be met by going to more than one physician - for example, if the chiropractor sends the patient to a medical doctor for their high blood pressure. If each charges $65.00, this is when Medicare jumps in and starts paying the 80%. But why do we have to pay $100 in December, then if we need to go back in January we have to pay the $100 again? A year is just starting but what if you only had one month of charges in the previous year? Why are the x-rays not covered by a chiropractor when they must x-ray before they can treat a person?

Until recently, in order for chiropractic care to qualify for Medicare coverage there was a Catch 22. Medicare required an annual x-ray, but did not cover the cost of the x-ray. The coverage was only for the chiropractor's "manual manipulation of the spine for correcting a subluxation." There are no limits to the number of treatments as long as they are medically necessary to correct a specific condition.

Medicare no longer requires the annual x-ray, and still does not provide any coverage for them. New chiropractic patients, or patients who have not had an x-ray for some time however, may still require an x-ray for their course of chiropractic treatment as you have pointed out.

There is an initial $100 annual deductible for Medicare Part B (medical services). The annual deductible period is January 1 through December 31. Even if you only require care in December and do not have enough charges to satisfy your $100 deductible, it starts all over again in the new calendar year. This works the same way for most Medigap health insurance as well. You or your Medigap insurance are responsible for the paying the $100 Part B deductible. Once that is paid for then Medicare pays 80% of the Medicare approved charges.

Medicare X-rays Coverage for Chiropractors

If you are on Medicare and you get X-rays taken by or for your chiropractor, you may need to watch your pocketbook starting in the near future. Chiropractors often take diagnostic X-rays when evaluating their patients, but since the year 2000, they have not been required to do so. Before then, if a chiropractor determined that her or his patient needed an "adjustment" (the hallmark of this treatment specialty), the burden of proof was on them, and they had to show - by means of x-rays that a subluxation existed in the patient’s spine. Because of that requirement, Centers for Medicare and Medicaid Services felt it was fair to reimburse patients for any radiology associated with chiropractic diagnosis (making an exception to the rule that all x-rays had to be ordered by patients’ primary physicians).

In 2000, the requirement to prove via x-ray that a spinal subluxation was present before administering chiropractic treatment was lifted. But the CMS continued to pay for diagnostic radiology provided by chiropractors just the same. Now they are proposing to do away with that reimbursement benefit.

Medicare is the largest payer of health care costs in the U.S. The proposed rule is accepting comments until August 31. On the CMS website, the file code for making comments is CMS-1385-P.

Medicare & Medicaid Coverage For Chiropractic Therapy

The Center for Medicare and Medicaid Services (CMS) has revised its requirements for chiropractic billing of "active/corrective" treatment and "maintenance" therapy.

Under the Medicare program, active therapy (AT) is a course of treatment that provides "reasonable expectation of recovery or improvement of function" whereas 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.

Under Medicare, chiropractic maintenance therapy is not considered medically reasonable or necessary and has never been a covered service. The 2003 Improper Medicare FFS Payments report indicates that chiropractors filed claims incorrectly 30.6% of the time and had the highest compliance error rate among the professions whose services are covered. The new policy was established with the hope that specifying which claims are for active/corrective therapy and which are for maintenance therapy will enable more accurate billing and facilitate the claims review process.

Under Medicare, coverage extends only to "treatment by means of manual manipulation of the spine to correct a subluxation," provided such treatment is legal in the State where performed. No other service furnished or ordered by chiropractors are covered.

In order for a treatment program to be considered active therapy (AT):

• The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment,
• 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 x-ray or physical exam.

Medicare regulations further describe "subluxations" as:

• 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.

Claims for spinal manipulation are billed with procedure codes 98940, 98941, or 98942. As of October 4, claims must include the AT modifier (e.g., 98940-AT) if active/corrective treatment is performed or no modifier if maintenance therapy is performed. Every claim for chiropractic active/corrective treatment with or without the AT modifier will continue to be denied if the services exceed frequency limits of "reasonable and necessary" services as defined by contracting that reviews the claims.

The policy manual also notes:

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as 3 months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.

Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already "set" and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.

Some chiropractors have been identified as using an "intensive care" concept of treatment. Under this approach multiple daily visits (as many as four or five in a single day) are given in the office or clinic and so-called room or ward fees are charged since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare will be limited to not more than one treatment per day.

Much of the problem with chiropractic Medicare claims is related to the way the law covering their services was written. In 1972, in response to vigorous lobbying by chiropractors, Congress called ordered limited coverage of chiropractic services under Medicare. The law, which took effect in 1973, called for payment for the treatment of "subluxations demonstrated by x-rays to exist." A few weeks after the law was passed, Doyl Taylor, head of the AMA Department of Investigation stated that when chiropractic inclusion appeared inevitable, the "subluxation" language was inserted with the hope of preventing chiropractors from actually being paid. The idea's originator thought that because chiropractic's traditional (metaphysical) "subluxation" were visible only to chiropractors, this provision would sabotage their coverage. After the law was passed, however, two things happened to enable payment. First, chiropractors held a consensus conference that redefined "subluxations" to include common findings that others could see. Second, according to Taylor, the government officials responsible for interpreting the new law "decided that Congress intended chiropractors to be paid for something." The regulators then defined subluxation as "an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae demonstrable . . . to individuals trained in the reading of x-rays" and stipulated that the "primary diagnosis" must be a subluxation.

The best strategy for patients who undergo chiropractic care for back pain is to stop going when they feel better. However, many chiropractors advise lifetime periodic spinal examinations and adjustments for what they call "preventative maintenance." Because "maintenance care" lacks a plausible rationale and has never been proven beneficial, insurance companies do not knowingly pay for it. The new Medicare regulations are an attempt to make it simpler to identify "maintenance care" so claims for it can be denied automatically.

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