Outlier reconciliation criteria for IPPS and LTCH PPS hospitals
View this information about outlier reconciliation criteria for IPPS and LTCH PPS hospitals and the latest CMS change request.
Where can I find diagnosis codes for chiropractic services?
For chiropractic services to be covered, they must be reasonable and necessary, and meet CMS guidelines. You can find diagnosis coding guidelines in our local coverage article, A58412 - Billing and Coding: Chiropractic Services.
What is modifier AT and when do we report it?
Modifier AT (active treatment) defines the difference between active treatment and maintenance treatment.
The AT modifier is required under Medicare billing to receive reimbursement for CPT codes 98940-98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active / corrective treatment (acute and chronic care).
Every chiropractic claim for 98940 / 98941 / 98942, should include the AT modifier if active / corrective treatment is being performed. Claims that do not contain modifier AT will deny.
Do First Coast medical review nurses deny chiropractic services based on medical necessity?
When your office receives a request for medical records to substantiate the chiropractic services you rendered and billed to Medicare, our nurse reviewers review the documentation and verify that all the required documentation has been met. If you met the documentation requirements, the nurse reviewers will send the documentation to a chiropractic consultant to determine the medical necessity of the services. If you did not meet the documentation requirements, the nurse reviewers will deny the services based on the lack of documentation.
I perform a thorough examination of my patient with the initial chiropractic visit, and then referred to the initial exam findings in my subsequent visit notes. Is this acceptable?
Yes, if you submit the initial examination findings with each billed subsequent visit when responding to medical documentation requested by us or the Comprehensive Error Rate Testing (CERT) program, it is acceptable.
We submitted X-ray reports with subsequent chiropractic visits, but they denied as out of date, why?
X-rays must be reasonably proximate to the initiation of a course of treatment. Unless more specific X-ray evidence is warranted, an X-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment.
In certain cases of chronic subluxation (e.g., scoliosis), an older X-ray may be accepted provided the beneficiary's record indicates the condition existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.
In chiropractic documentation, must we document the treatment effectiveness for each billed date of service?
Yes, the documentation must indicate an evaluation of the effectiveness of the treatment provided for subsequent visits.
In chiropractic documentation, can regions identified in the exam component be inferred as regions adjusted?
No, the documentation must state the specific regions adjusted.
Is it acceptable for a chiropractor to use his/her own abbreviations in the medical records, i.e., abbreviations other than those widely used by chiropractors?
Abbreviations commonly used within any specialty are acceptable. However, if your patients' medical records contain abbreviations not commonly used, and you receive a request for medical records, please provide a key to the abbreviations. Submit the key with the medical records to assist us in the review.
What are the differences in the documentation requirements for an acute problem vs. a chronic problem?
Documentation for an acute problem should indicate an expectation treatment will result in the improvement in or arrest of progression of the patient's condition.
Documentation for a chronic problem should indicate an expectation stabilization or continued treatment will result in some functional improvement in the patient's condition.