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Table of Contents
General Practices and Coverage Guidelines .................................................................1
I. Licensure and Authorization to Practice......................................................................................................................... 1
II. Chiropractic Coverage Guidelines................................................................................................................................. 1
III. What is Subluxation? ................................................................................................................................................... 2
IV. Demonstrating Subluxation.......................................................................................................................................... 3
V. Location of Subluxation ................................................................................................................................................ 4
Initial and Subsequent Visit Documentation .................................................................8
I. Initial Visit Documentation .............................................................................................................................................. 8
II. Subsequent Visit Documentation .................................................................................................................................. 9
Documentation and Medical Review ............................................................................10
I. Why Is Documentation Important? ............................................................................................................................... 10
II. Purpose of Medical Records ....................................................................................................................................... 10
III. Legal Signature Must Be Identifiable and Legible ...................................................................................................... 11
IV. Illegible Documentation and Graphs.......................................................................................................................... 11
V. Use of Specialty Jargon .............................................................................................................................................. 11
VI. The Use of Check Lists.............................................................................................................................................. 12
VII. The Establishment of Patient Goals.......................................................................................................................... 12
VIII. Maintenance Therapy Is Not A Covered Benefit...................................................................................................... 12
IX. Treatment Must Be Reasonable and Necessary ....................................................................................................... 12
X. The Regions and Levels Treated Must Be Identified .................................................................................................. 13
XI. Date of Service Not Identified .................................................................................................................................... 13
XII. Medical Record Review ............................................................................................................................................ 13
XIII. How to Avoid Documentation Pitfalls ....................................................................................................................... 14
XIV. Local Coverage Determination ................................................................................................................................ 14
Claims Filing...................................................................................................................15
I. Frequency of Chiropractic Visits................................................................................................................................... 15
II. Applicable CPT/HCPCS Codes................................................................................................................................... 15
III. ICD-9-CM Codes that Support Medical Necessity ..................................................................................................... 15
IV. Special Requirements for Chiropractic Claims........................................................................................................... 17
V. HCPCS Modifier AT.................................................................................................................................................... 17
VI. Modifier Use............................................................................................................................................................... 18
VII. Remittance Advice Guide (RA) ................................................................................................................................. 18
VIII. Common Claim Denials ........................................................................................................................................... 18
Limitation of Liability (Advance Beneficiary Notice of Noncoverage).......................20
I. Advanced Beneficiary Notice (ABN)............................................................................................................................. 20
II. ABN Modifiers ............................................................................................................................................................. 20
Addressing Misinformation Regarding Chiropractic Services and Medicare...........21
I. Background .................................................................................................................................................................. 21
II. Specifically Addressed Issues..................................................................................................................................... 21
The National Correct Coding Initiative (NCCI) .............................................................23
I. What is the NCCI? ....................................................................................................................................................... 23
II. Medicare Appeals ....................................................................................................................................................... 23
Fee Schedules ................................................................................................................24
Participating versus Non Participating Provider .........................................................25
I. Enrolling in the Medicare Program ............................................................................................................................... 25
II. The Participation Program .......................................................................................................................................... 26
III. The Annual Open Participation Enrollment Period ..................................................................................................... 26
IV. What Is Participation?................................................................................................................................................ 26
V. Benefits of Participation .............................................................................................................................................. 26
VI. Assigned Claims ........................................................................................................................................................ 27
VII. Nonassigned Claims ................................................................................................................................................. 27
VIII. Opting Out of Medicare............................................................................................................................................ 27
Comprehensive Error Rate Testing (CERT) Program .................................................28
Recovery Audit Contractor (RAC).................................................................................29
I. What is RAC?............................................................................................................................................................... 29
II. Contact J1 RAC Health Data Insight, Inc. ................................................................................................................... 29
III. RAC Contractor Reviews ........................................................................................................................................... 29
IV. 2009 Medical Record Limits....................................................................................................................................... 30
V. What is different?........................................................................................................................................................ 30
VI. Prepare for Implementation ....................................................................................................................................... 30
VII. RAC Resources at the CMS Web site ...................................................................................................................... 30
Chiropractic Specialty Resources ................................................................................31
Contact Us ......................................................................................................................31
Appendix
Chiropractic Billing and Documentation Checklist
Comprehensive Error Rate Testing (CERT) Part B Chiropractic Checklist
General Practices and Coverage Guidelines
I. Licensure and Authorization to Practice

A chiropractor must be licensed or legally authorized to render Chiropractic services by the
State or jurisdiction in which the services are rendered. Coverage extends only to treatment by
means of manual manipulation of the spine to correct a subluxation demonstrated by X-ray or
physical exam, provided such treatment is legal in the state where performed. All other
services rendered or ordered by a chiropractor are considered non-covered.
Chiropractors Licensed or Authorized to Practice Prior to July 1, 1974

Chiropractors licensed or authorized to practice prior to July 1, 1974, and those individuals
who commenced their studies in a Chiropractic college before that date must meet all of the
following three minimum standards to render payable services under the program:
 Preliminary education equal to the requirements for graduation from an accredited high
school or other secondary school;
 Graduation from a college of Chiropractic approved by the State’s Chiropractic examiners
that included the completion of a course of study covering a period of not less than three
school years of six months each year in actual continuous attendance covering adequate
course of study in the subjects of anatomy, physiology, symptomatology and diagnosis,
hygiene and sanitation, chemistry, histology, pathology, and principles and practice of
Chiropractic, including clinical instruction in vertebral palpation, nerve tracing, and
adjusting; and
 Passage of an examination prescribed by the State’s Chiropractic examiners covering the
subjects listed above.
II. Chiropractic Coverage Guidelines

What Is Covered?
The only chiropractic service covered by Medicare is manual manipulation of the spine. No
other diagnostic or therapeutic services furnished by a chiropractor, or furnished on his/her
order, are covered. The treatment must be medically necessary and the services must provide
a reasonable expectation of recovery or improvement of function.
Coverage Criteria
The patient must have a significant health problem in the form of a neuromusculoskeletal
condition necessitating treatment and the services must have a direct therapeutic relationship
to the patient’s condition.
HCPCS Modifier AT
When a chiropractor provides active/corrective treatment, for either acute or chronic
subluxation, the service must be submitted with HCPCS modifier AT. If the service qualifies as
“maintenance therapy,” it must be submitted without HCPCS modifier AT and the service will
be denied. Use of HCPCS modifier AT does not automatically mean the service meets the
February 2010 Palmetto GBA J1 Part B Chiropractic Services Billing Guide Page 1
“medical necessity” guidelines. Again, the patient’s medical record must support the use of this
modifier.
Frequency of Chiropractic Visits

There is no set limit on the number of treatments. For acute subluxation problems, the patient’s
condition will determine the frequency. In the first few days, treatment may be quite frequent
but will decrease over time or as the patient’s condition improves. “Chronic” subluxation
implies that the condition has existed for a longer period of time, so the involved joints may
have set. Thus, Chronic conditions may require a longer treatment time, but not at a higher
frequency. Medicare will reimburse one treatment per day unless documentation supporting
the medical necessity for additional services is submitted with each claim.
Coverage of Chiropractic service is specifically limited to treatment by means of manual

manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-
held with the thrust of the force of the device being controlled manually) may be used by
chiropractors in performing manual manipulation of the spine. However, no additional payment
is available for use of the device, nor does Medicare recognize an extra charge for the device
itself.
No other diagnostic or therapeutic service furnished by a chiropractor or ordered by a

chiropractor is covered. This means that if a chiropractor orders, performs or interprets an X-
ray or any other diagnostic test, the X-ray or other diagnostic test, can be used to document
medical necessity for claims processing purposes, but Medicare coverage and payment will
not be available for those services when provided by a chiropractor. This prohibition does not
affect the coverage of X-rays or other diagnostic tests furnished by other practitioners under
the program. For example, an X-ray or any diagnostic test taken for the purpose of determining
or demonstrating the existence of a subluxation of the spine is a diagnostic X-ray test covered
if ordered, performed and interpreted by a physician who is a doctor of medicine or osteopathy.
Compliance with the provisions in this policy is subject to monitoring by post payment data
analysis and subsequent medical review.
III. What is Subluxation?

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 surfaces remains
intact.
A subluxation may be demonstrated by an X-ray or by physical examination, as described
below.
IV. Demonstrating Subluxation

By X-ray (Ordered, Taken or Interpreted)
Effective for claims with dates of service on or after January 1, 2000, an X-ray is not required
to demonstrate subluxation. However, an X-ray may continue to be used for this purpose if
desired.
There is no requirement for chiropractors to obtain X-rays prior to treatment. If subluxation is

demonstrated by X-ray, there is no requirement for:
• X-ray at each level of subluxation

• Repeat X-rays for patients with chronic conditions
X-rays that are ordered, taken or interpreted by chiropractors can be used for claims
processing purposes, but they are not covered by Medicare. X-rays that are ordered, taken, or
interpreted by MDs or DOs may be covered.
When using an X-ray to document subluxation, the X-ray must have been taken at a time
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 three 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 health record indicates the condition has existed longer
than 12 months and there is a reasonable basis for concluding that the condition is permanent.
A previous CT scan and/or MRI are acceptable evidence if a subluxation of the spine is
demonstrated.
By Physical Examination
Demonstrating subluxation by physical examination requires an evaluation of
musculoskeletal/nervous system. If subluxation is demonstrated by physical exam, the medical
record must include two of the following four criteria, one of which must be #2 or #3.
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.
The history recorded in the patient record should include the following:
 Symptoms causing patient to seek treatment
 Family history if relevant
 Past health history (general health, prior illness, injuries, or hospitalizations; medications or
surgical history)
 Mechanism of trauma
 Quality and character of symptoms/problem
 Onset, duration, intensity, frequency, location and radiation of symptoms
 Aggravating or relieving factors; and
 Prior interventions, treatments, medications, secondary complaints
Acute Subluxation
Acute Subluxation means the patient is being treated for a new injury. The X-ray date or other
diagnostic test, first date of treatment and diagnosis must be reasonably proximate. However,
result is expected to be an improvement in, arrest or retardation of the patient’s condition.
Chronic Subluxation
Chronic condition is not expected to completely resolve. The result is expected to be “some
functional improvement.” Once the patient’s functional status has remained stable for that
condition, further manipulative treatment is considered “maintenance therapy” and is not
covered.
Spinal Areas/Vertebrae
The level of subluxation must be identified in the documentation.
V. Location of Subluxation
The precise level of the subluxation must be specified by the chiropractor to substantiate a
claim for manipulation of the spine. This designation is made in relation to the part of the spine
in which the subluxation is identified:
Number of Short Form or
Area of Spine Names of Vertebrae
Vertebrae Other Name
Neck Occiput 7 Occ, CO
Cervical C1 through C7
Atlas C1
Axis C2
Back Dorsal 12 D1 through D12
Thoracic T1 through T12
Costovertebral R1 through R12
Costotransverse R1 through R12
Low Back Lumbar 5 L1 through L5
Sacral Sacrum or Coccyx S, SC
Pelvis Iliac bones, R and L I, Si
In addition to the vertebrae and pelvic bones listed, the Iliac bones (R and L) are included with
the sacrum as an area where a condition may occur which would be appropriate for
chiropractic manipulative treatment.
There are two ways in which the level of the subluxation may be specified.
1. The exact bones may be listed, for example: C5, C6, etc
2. The area may suffice if it implies only certain bones such as occipito-atlantal (occiput
and C1 (atlas)), lumbo-sacral (L5 and sacrum) and sacral-iliac (sacrum and ilium)
The nature of the subluxation must be identified in your documentation. See below for some
common examples of acceptable descriptive terms:
 Off-centered
 Misalignment
 Malpositioning
 Spacing - abnormal, altered, decreased or increased
 Incomplete dislocation
 Rotation
 Listhesis - antero, postero, retro, lateral and spondylo
 Motion-limited, lost, restricted, flexion, extension, hypermobility, hypomotility or aberrant
Other terms may be used and are acceptable if they are understood clearly to refer to bone or
joint space or position (or motion) changes of vertebral elements.
Manual Manipulation Synonyms

 Correction
 Treatment
 Spine or spinal adjustment by manual means
 Spine or spinal manipulation
 Manual adjustment
 Vertebral manipulation or adjustment
Manipulation is not covered when:

 An absolute contraindication exists
 Mechanical or electrical equipment is used
 The X-ray or diagnostic test does not support one of the primary covered diagnoses
 The claim lacks one of the primary covered diagnoses
 Claim is submitted with CPT code 98943. Medicare never covers CPT code 98943
(extraspinal manipulation)
Contraindications
Certain conditions add a significant risk of injury to the patient when dynamic thrust is
performed:
 Relative contraindications
 Absolute contraindications
Relative Contraindications
For relative contraindications, the chiropractor should discuss the risks with the patient and
record notes about the discussion in the beneficiary's medical record. Relative
contraindications to dynamic thrust are:
 Articular hypermobility and circumstances where the stability of joint is uncertain
 Severe demineralization of bone
 Benign bone tumors (spine)
 Bleeding disorders and anticoagulant therapy
 Radiculopathy with progressive neurological signs
Absolute Contraindications
 Acute arthropathies characterized by acute inflammation and ligamentous laxity and
anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing
spondylitis
 Acute fractures and dislocations or healed fractures and dislocations with signs of instability
 An unstable os odontoideum
 Malignancies that involve the vertebral column
 Infection of bones or joints of the vertebral column
 Signs and symptoms of myelopathy or cauda equina syndrome
 For cervical spinal manipulations, vertebrobasilar insufficiency syndrome
 Significant major artery aneurysm near the proposed manipulation
What is Maintenance Therapy?

The Centers for Medicare and Medicaid (CMS) defines maintenance therapy 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.”
Continued repetitive treatments without an achievable, clearly-defined goal are considered
maintenance therapy. Medicare does not cover maintenance therapy.
Non-Covered Services
When rendered, performed or interpreted by a chiropractor, the following services are not
covered:
 X-rays
 Physical Therapy
 Treatment for diagnoses which are not considered to be medically necessary
 Office visits
 Manipulation of body parts other than the spine
 Laboratory tests
 Traction
 Supplies
 Drugs/Injections
 EKGs or other diagnostic tests
 Nutritional supplements/counseling
 Services ordered by chiropractors
Initial and Subsequent Visit Documentation
I. Initial Visit Documentation

The following information must be documented in the patient's clinical record on the initial visit.
 History: chief complaint including the symptoms present that caused the patient to seek
Chiropractic treatment
o Symptoms causing patient to seek treatment
o Family history, relevant
o Past health history
o Mechanism of trauma
o Quality and character of symptoms/problem
o Onset, duration, intensity, frequency, location and radiation of symptoms
o Aggravating or relieving factors
o Prior interventions, treatments, medications or secondary complaints
 Present Illness: This can include any of the following as appropriate

o Mechanism of trauma
o Quality and character of problem/symptoms
o Intensity of symptoms
o Frequency of symptoms occurring
o Location and radiation of symptoms
o Onset of symptoms
o Duration of symptoms
o Aggravating or relieving factors of symptoms
o Prior interventions, treatments, including medications
o Secondary complaints
o Symptoms causing patient to seek treatment.
 Family History (If pertinent): Past health history which may include
o General health statement
o Prior illness(es)
o Surgical history
o Prior injuries or traumas
o Past hospitalizations (as appropriate)
o Medications
 Physical Examination: Evaluation of the musculoskeletal/ nervous system through

physical examination
o Pain/tenderness evaluated in terms of location, quality and intensity
o Asymmetry/misalignment identified on a sectional or segmental level
o Range of motion abnormality (changes in active, passive and accessory joint
movements resulting in an increase or a decrease of sectional or segmental mobility)
o Tissue, tone changes in the characteristics of contiguous or associated soft tissues,
including skin, fascia, muscle and ligament
 Diagnosis: A primary or secondary diagnosis must be determined during an initial visit.
o Required Primary Diagnosis
The primary diagnosis must be subluxation, including the level of subluxation either so
stated or identified by a term descriptive of subluxation. Such terms may refer either to
the condition of the spinal joint involved or to the direction of position assumed by the
particular bone named.
o Required Secondary Diagnosis
The secondary diagnosis should come from Category I, II or III diagnosis (See the ICD-
9-CM Codes That Support Medical Necessity Section of this document)
 Treatment Plan: The treatment plan should include the following

o Therapeutic modalities to effect cure or relief (patient education and exercise training)
o The recommended level of care (the duration and frequency of visits)
o Specific goals that are expected to be achieved with treatment
o Objective measures to evaluate treatment effectiveness
o Date of initial treatment
Sample Treatment Plan

05-05-06 CMT and adjunctive modalities daily for 1 week and 3x/wk for the following 2
weeks. Re-eval at that time; Off work 2 weeks.
Short term goals

 Minimize pain(<3) and spasm
 Increase pain free LS flexion (>45)
Long term goals

 Restore ability to tie shoes w/o pain
 Sit/stand for prolonged periods (>2hrs.)
 Get in and out of vehicles w/o difficulty
 Return normal sleep patterns
II. Subsequent Visit Documentation

The following documentation requirements apply whether the subluxation is demonstrated by
X-ray or by physical examination for subsequent visits:
 History
o Review of chief complaint
o Changes since last visit
o System review, if relevant
 Physical exam
o Exam of area of spine involved in diagnosis
o Assessment of change in patient condition since last visit
o Evaluation of treatment effectiveness
 Notation of treatment given on day of visit
o Documentation of treatment given on the day of the visit. Do not just refer to the plan
from the initial visit without also giving the current day’s findings.
SOAP Note
S: Review of chief complaint, note any changes since the last visit and review of systems if
relevant
O/A: Physical/regional exam. Examine the area of the spine involved in the diagnosis and note
findings. Assess change in the beneficiary's condition since the last visit. Evaluate the
treatment for effectiveness.
P: Document the treatment given on the day of the visit and any adjunctive therapy.
Sample Subsequent Note

05-15-06: Patient notes diminished intensity/frequency of LBP. VAS decreased to 4/10. Overall
lumbar paraspinal spasm/tenderness bilaterally, but decreased since last visit. Joint fixation at
L4-L5 and right SI. Condition resolving. L5 RSI adjusted with side posture. Continue treatment
plan as prescribed on initial visit on 05-05-06. Return Tuesday. Dr. Signature
Documentation and Medical Review
I. Why Is Documentation Important?

Clinical Documentation is an important source of evidence when the services provided are
reviewed. It provides a legal, historical account of encounters with a beneficiary, it ensures the
services were provided safely and effectively. It also shows compliance with federal, state,
payor, and local requirements. Documentation establishes support for reimbursement of
services, may be a basis for research and serves as a communication vehicle between other
disciplines and/or providers.
Abbreviations “Abbreviations can cause legal nightmares. What you document must be
understandable today and in the future. If you get creative and deviate from the approved
abbreviation list, how can you prove what you meant by the abbreviation?”
“Abbreviations: A Shortcut to Disaster” by Fay Yocum, MSN, RN

 HA: Heart attack or headache?
 HL: Heparin lock or Hickman line?
 SOB: Shortness of breath or side of bed?
II. Purpose of Medical Records

The intent of all records is to communicate unmistakably with other health care professionals,
legal advocates, insurance company staff, beneficiaries and other approved readers, of what
has transpired with each medical contact with that patient. In the world of insurance billing, you
can expect delays in payment and a possibility of placement into medical review if your
documentation is deficient. Required items that are absent or problems found within the
documentation provided are the two most obvious causes for delay and denial. However, there
are some sound suggestions that can eliminate the more obvious problems that create delay
of claims or denial in the adjudication process.
III. Legal Signature Must Be Identifiable and Legible

The chiropractor must ensure that he or she has signed their name and title legally and legibly.
When signing your name, please make sure that you include your first name, last name
followed by your credential or license for proper identification. Medicare never accepts
stamped signatures. Please review the legal signature article published in the September 2009
Medicare Advisory on the Palmetto J1 Part B Web site, under ‘Publications’.
IV. Illegible Documentation and Graphs

Illegible documentation is the same as non-documentation. If the letters of the alphabet are not
recognizable in a sentence or phrase, it is illegible. The use of unapproved abbreviations or
symbols is automatically a negative. Medicare will reject in-house graphs that lack legends or
keys. Many of the submitted self-designed graphs are so small they are unintelligible or
indecipherable to another reader. Remember that the ink or print has to be dark enough to
reproduce readable facsimile or Xerox; the graph entries will not be visible to the reviewer
otherwise. Remember, even with the use of graphs, the identifiable treatment or procedure
must have a legal signature and credential attached to it.
Illegible Handwriting: What is this order for?
V. Use of Specialty Jargon

Professionals in the same specialty or practice arena often use the same "shop talk" and
jargon. Keep in mind that other people will read the medical record and will have a difficult time
deciphering words that are “short cuts” of accepted medical words and procedures. These
uses of shortcut terms also equate to being non-comprehensible, non-meaningful and are
open for ruling as deniable documentation. Use of jargon is not necessarily a purposeful fraud
event or illegal event, but it is clearly a non-readable, non-understandable entry. This will not
support a claim for services rendered. You are expected to write in English, using good
grammar and proper punctuation.
VI. The Use of Check Lists

The use of check lists or check boxes to verify a condition, to verify a treatment was given, to
verify a patient was seen or to confirm the reoccurrence of a condition is not acceptable, as is.
In the view of Medicare, each written contact with the patient must stand alone. A check box
does not indicate the date of the original injury. The Chiropractor must always think of the
contact with the patient from a fresh or new viewpoint regarding each contact. With that in
mind, anyone looking over the record would want to read a complete note that would include
subjective, objective, assessment and plan of care information. Many check boxes Medicare
reviews indicate that the same condition prevails, with the same treatment. What a check box
does not convey is has there been any progress. When there is no history or not even a listing
for a chief complaint present that would explain why the patient needs to see a Chiropractor,
there is no way that Medicare can determine the medical need or reasonableness of the visit.
A well-written medical note is tailored made for each visit.
VII. The Establishment of Patient Goals

With all therapies and treatments, Chiropractors must set realistic goals and perform
recertification of need if therapy has to continue. It is an important component for any
treatment rendered and any further treatments required. Medicare requires evidence of
evaluating future or former treatments. Furthermore, there must be a time frame given for the
patient to realize a comfort zone again or an ability to function with Activities of Daily Living that
is gained from short-term therapy.
VIII. Maintenance Therapy Is Not A Covered Benefit

The Chiropractic practitioner must remember that Medicare decisions are driven by the Social
Security Act which states, “Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage
and payment for only those services that are considered to be medically reasonable and
necessary." That means medical necessity of a service is the overarching criterion for
Medicare payment. Therefore, the focus of the Medicare service medical note must be
describing work related to acute care or well documented exacerbations. If the note focuses on
describing what is termed maintenance therapy, the treatment will not be a covered. A
Chiropractic chart entry must clearly discern which service is chronic care or acute care. When
a provider implies that a condition is chronic and the treatment will have to continue
indefinitely, such service conflict with the Medicare focus on acute care. As a result, treatment
for the condition is more likely to be determined as a maintenance therapy treatment.
IX. Treatment Must Be Reasonable and Necessary

Providers must also understand that there has to be reasonableness when documenting an
exacerbation. A patient's condition is chronic when there is no expectation of significant
improvement or resolution with further treatment. The medical review process has discovered
that providers are referring to injuries that occurred five or ten years ago or even further back
in history. When the documentation does not meet the criteria for the service rendered or the
documentation does not establish the medical necessity for the services, such services will be
denied as not reasonable and necessary. Title XVIII of the Social Security Act, 1862(a)(1)(A) :
Allows coverage and payment for only those services that are considered to be medically
reasonable and necessary.
Title XVIII of the Social Security Act, 1833(e): Prohibits Medicare payment for any claim, which
lacks the necessary information to process the claim.
X. The Regions and Levels Treated Must Be Identified

During a Chiropractic session, there must be documentation of the treated regions or levels.
To support Chiropractic treatment, there must be identification of a physical part of the body
and specific area(s) adjusted; an absence of physical location or spinal column reference
interrupts the adjudication process for lack of documentation.
XI. Date of Service Not Identified

Many documents reviewed at Medicare lack a date of service on them. When a provider is
asked to send in documentation for medical review (or any audit), it is essential that the dates
of service (that the review process may be inquiring about) be on all the documents being sent
in. Identify dates otherwise left off documentation. Place dates of services, dates of review,
dates of summary, dates of letters, dates on any legal chart sheet, etc., in a visible place. Write
legibly on each document.
As with any audit process, you can use this information to perform some quality control
practices for use on your future documentation.
Make sure that you:

 Sign all documents with a legal signature
 Make all documentation legible and readable
 Avoid the use of jargon
 Decrease the use of graphs in documentation or improve the reproduction quality and the
interpretation of graphs in documentation
 State patient goals and the timeframes to reach those goals
 Document all regular and routine evaluation efforts
 Do not perform maintenance therapy
 Give services that are both reasonable and necessary
 Identify the areas of the body that needs treatment with supporting objective and subjective
data
 Identify the date of every patient contact on each document on which you make an entry
XII. Medical Record Review

Do your medical records contain:
 Patient’s name on each page
 Dates for every entry
 Legible entries
 Legible signatures for each patient encounter
 Precise subluxation(s) documented by physical exam or X-ray
 A complaint consistent with subluxation levels found
 A past health history
 A check for contraindications
 Quality and intensity of chief complaint
 Aggravating and relieving factors
 Physical exam substantiating the condition and the subluxation
 Primary diagnosis of subluxation
 Treatment plan with measureable specific goals and timeframe
 Progress toward goals
 Medical necessity substantiated
 History – for a subsequent visit
 Notations of specific changes
 The adjustment clearly recorded as being accomplished
 Notations on the effectiveness of treatment that would qualitatively and quantitatively
substantiate the need and frequency of treatment
The adjustment is for acute or chronic care (or maintenance care along with the appropriate
documentation)
XIII. How to Avoid Documentation Pitfalls

 Look for pages without any patient identification
 Document at the same time as the intervention if you can, or as close to it as possible
 Do not leave blank space so you can add more documentation later
 Documentation that's later squeezed into the space available could look like a cover-up or,
more generally, raise questions about why documentation was done after the fact
 Make sure you have the right chart before you begin writing
 Write legibly
 Do not alter a patient record
 Do not chart ahead of time
XIV. Local Coverage Determination

The Chiropractic Service LCD (L28249) is applicable to Northern California, Southern
California, Nevada, American Samoa, Guam, Hawaii and Northern Mariana Islands. Click
below to review the LCD for your region.
 Northern California
www.cms.hhs.gov/mcd/results_index.asp?from='articlecontractor'&contractor=174&name=
Palmetto+GBA+%2801102%2C+MAC+%2D+Part+B%29&letter_range=4
 Southern California
www.cms.hhs.gov/mcd/results_index.asp?from='lmrpstate'&contractor=177&name=Palmett
o+GBA+%2801192%2C+MAC+%2D+Part+B%29&letter_range=4
 Nevada
 Hawaii, American Samoa, Marianna Islands and Guam
Claims Filing
I. Frequency of Chiropractic Visits

As previously mentioned, there is no set limit on the number of treatments. For acute
subluxation problems, the patient’s condition will determine the frequency. In the first few days,
treatment may be quite frequent but will decrease over time or as the patient’s condition
improves. “Chronic” subluxation implies that the condition has existed for a longer period of
time, so the involved joints may have set. Thus, chronic conditions may require a longer
treatment time, but not at a higher frequency. Medicare will reimburse one treatment per day
unless documentation supporting the medical necessity for additional services is submitted
with each claim.
II. Applicable CPT/HCPCS Codes

CPT Code Description
98940 Chiropractic Manipulative Treatment (CMT); Spinal, 1-2 Regions
98941 Chiropractic Manipulative Treatment (CMT); Spinal, 3-4 Regions
98942 Chiropractic Manipulative Treatment (CMT); Spinal, 5 Regions
98943* Chiropractic Manipulative Treatment (CMT); Extra Spinal, 1 or more regions
* CPT code 98943 is not a Medicare benefit.
III. ICD-9-CM Codes that Support Medical Necessity

These are the only covered ICD-9-CM codes that support medical necessity.
Required Primary ICD-9-CM Codes (Names of Vertebrae)

The precise level of subluxation must be listed as the primary diagnosis.
ICD-9-CM
Description
Codes
739.0 Nonallopathic Lesions of Head Region Not Elsewhere Classified
739.1 Nonallopathic Lesions of Cervical Region Not Elsewhere Classified
739.2 Nonallopathic Lesions of Thoracic Region Not Elsewhere Classified
739.3 Nonallopathic Lesions of Lumbar Region Not Elsewhere Classified
739.4 Nonallopathic Lesions of Sacral Region Not Elsewhere Classified
739.5 Nonallopathic Lesions of Pelvic Region Not Elsewhere Classified
Required Secondary ICD-9-CM Codes
 Category I: ICD-9-CM diagnosis that generally require short term treatment
ICD-9-CM
Description
Codes
307.81 Tension Headache
718.48 Contracture of Joint of Other Specified Sites
721.0 Cervical Sondylosis Without Myelopathy
721.2 Thoracic Sondylosis Without Myelopathy
721.3 Lumbosacral Sondylosis Without Myelopathy
721.6 Ankylosing Vertebral Hyperostosis
721.90 Sondylosis of Unspecified Site Without Myelopathy
721.91 Sondylosis of Unspecified Site with Myelopathy
723.1 Cervicalgia
724.1 Pain in Thoracic Spine
724.2 Lumbago
724.5 Backache Unspecified
784.0 Headache
 Category II: ICD-9-CM diagnoses that generally require moderate term treatment
ICD-9-CM
Description
Codes
353.0 Brachial Plexus Lesions
353.1 Lumbosacral Plexus Lesions
353.2 Cervical Root Lesions Not Elsewhere Classified
353.3 Thoracic Root Lesions Not Elsewhere Classified
353.4 Lumbosacral Root Lesions Not Elsewhere Classified
353.8 Other Nerve Root And Plexus Disorders
719.48 Pain In Joint Involving Other Specified Sites
720.1 Spinal Enthesopathy
722.91 Other And Unspecified Disc Disorder of Cervical Region
722.92 Other And Unspecified Disc Disorder of Thoracic Region
722.93 Other And Unspecified Disc Disorder of LUMBAR Region
723.0 Spinal Stenosis In Cervical Region
723.2 Cervicocranial Syndrome
723.3 Cervicobrachial Syndrome (Diffuse)
723.4 Brachial Neuritis or Radiculitis Nos
723.5 Torticollis Unspecified
724.01 Spinal Stenosis of Thoracic Region
724.02 Spinal Stenosis of Lumbar Region
724.4 Thoracic orLumbosacral Neuritis or Radiculitis Unspecified
724.6 Disorders of Sacrum
724.79 Other Disorders of Coccyx
724.8 Other Symptoms Referable to Back
729.1 Myalgia And Myositis Unspecified
729.4 Fasciitis Unspecified
738.4 Acquired Spondylolisthesis
ICD-9-CM
Description
Codes
756.12 Spondylolisthesis Congenital
846.0 Lumbosacral (Joint) (Ligament) Sprain
846.1 Sacroiliac (Ligament) Sprain
846.2 Sacrospinatus (Ligament) Sprain
846.3 Sacrotuberous (Ligament) Sprain
846.8 Other Specified Sites of Sacroiliac Region Sprain
847.0 Neck Sprain
847.1 Thoracic Sprain
847.2 Lumbar Sprain
847.3 Sprain of Sacrum
847.4 Sprain of Coccyx
 Category III: ICD-9-CM diagnoses that may require long term treatment
ICD-9-CM
Description
Codes
721.7 Traumatic Spondylopathy
722.0 Displacement of Cervical Intervertebral Disc Without Myelopathy
722.10 Displacement of Lumbar Intervertebral Disc Without Myelopathy
722.11 Displacement of Thoracic Intervertebral Disc Without Myelopathy
722.4 Degeneration of Cervical Intervertebral Disc
722.51 Degeneration of Thoracic or Thoracolumbar Intervertebral Disc
722.52 Degeneration of Lumbar or Lumbosacral Intervertebral Disc
722.6 Degeneration of Intervertebral Disc Site Unspecified
722.81 Postlaminectomy Syndrome of Cervical Region
722.82 Postlaminectomy Syndrome of Thoracic Region
722.83 Postlaminectomy Syndrome of Lumbar Region
724.3 Sciatica
Submission of these codes does not guarantee reimbursement. The patient's medical record
must document that Medicare coverage criteria have been met.
IV. Special Requirements for Chiropractic Claims

Requirements CMS-1500 Claim Form Electronic Claims (ANSI 4010A1)
Initial Treatment Date Item 14 Loop 2300. DTP/439.03
X-ray Date (if using X-ray Item 19 Loop 2300. DTP/455.03 or Loop
to demonstrate 2400, DTP/455.03
subluxation)
Diagnosis of subluxation Item 21 Loop 2300. HI, 01-2
V. HCPCS Modifier AT
As a reminder, when a chiropractor provides active/corrective treatment, for either acute or
chronic subluxation, the service must be submitted with HCPCS modifier AT.
If the service qualifies as “maintenance therapy,” it must be submitted without HCPCS modifier
AT and the service will be denied.
Use of HCPCS modifier AT does not automatically mean the service meets the “medical
necessity” guidelines.
The patient’s medical record must support the use of this modifier.
VI. Modifier Use

HCPCS Modifier Description
AT Patient under active or corrective treatment
Doctor of Chiropractic has patient under active treatment but feels
AT + GA*
Medicare may deem as not medically necessary
* Please refer to the Limitation of Liability (Advance Beneficiary Notice of Noncoverage)

section of this Guide for additional ABN and modifiers information.
VII. Remittance Advice Guide (RA)

The Remittance Advice is designed for providers, physicians, suppliers and billers. Visit the
CMS Web site at www.cms.hhs.gov/MLNProducts for more information on
 The components of RA
 Sample and description of Electronic Remittance Advice (ERA)
 Sample and description of Standard Paper Remittance (SPR)
VIII. Common Claim Denials
Financial Responsibility
Patient Responsibility (PR) Contractual Obligation (CO)
Missing Claims Data

 MA122 Missing/incomplete/invalid initial treatment date
 Resubmit the claim
 Include the initial treatment date in Item 14 of the claim form or its electronic equivalent
Medically Unnecessary Services

 Non-acute conditions that do not meet medical necessity
 Acute conditions that do not show reasonable expectation of recovery or improvement of
function
Services Incorrectly Coded

 Upcoding: Billing for preventive or maintenance care on areas in excess of the acute-
condition regions under active treatment
 Failure to use the GZ modifier, if advance notice of non-coverage was not provided to the
patient
Insufficient Documentation
 Patient’s name not on each page of documentation
 Physician signature missing or illegible for each date of service and/or the service
 Actual treatments not documented
 Missing medical necessity for the treatment of an acute condition
 Lacking measurable goals and time period for improvement during initial visit
 Subsequent visits lacking key items of the: history, physical exam, and documentation of
treatment
 Lacking progress toward goals in subsequent visits
Limitation of Liability (Advance Beneficiary Notice of Noncoverage)
Services denied as not reasonable and medically necessary, under section 1862(a)(1) of the
Social Security Act, are subject to the Limitation of Liability (Advance Beneficiary Notice (ABN)
provision). Thus, to be held liable for denied charge (s), the beneficiary must be given
appropriate written advance notice of the likelihood of non-coverage and agree to pay for
services. A written notice covering an extended course of treatment is acceptable, provided the
notice identifies all services for which the provider believes Medicare will not pay. If as the
course of treatment progresses, additional services are furnished for which the provider
believes Medicare will not pay, the provider must separately notify the patient in writing that
Medicare is not likely to pay for the additional services and obtain the beneficiary’s signed
statement agreeing to pay.
I. Advanced Beneficiary Notice (ABN)

Use ABN Form (CMS-R-131) for services for which Medicare is likely to deny payment due to
frequency or medical necessity.
Examples of when you should ask the patient to sign an ABN:

• Treatment is given for a diagnosis not related to subluxation
• Treatment is given for maintenance therapy
If patient refuses to sign, notate refusal on form, have two staff members sign and date form,
submit claim with HCPCS modifier GA. References www.cms.hhs.gov/BNI/01_overview.asp
Complete instructions and ABN forms are available on the CMS Web site at the following
address: http://cms.hhs.gov/BNI/
II. ABN Modifiers

Financial Responsibility Modifiers
HCPCS
Description Financial Responsibility
Modifier
GA ABN on file Patient
GZ Service expected to be denied as not Contractual Obligation
reasonable and necessary
GY Statutorily excluded or not a Medicare Patient
benefit
 Modifier GA should be used when physicians, practitioners, or suppliers want to indicate
that they expect that Medicare will deny an item or service as reasonable and necessary
and they have on file an ABN signed by the beneficiary.
 Modifier GY should be used when physicians, practitioners, or suppliers want to indicate

that the item or service is statutorily non-covered, or is not a Medicare benefit.
 Modifier GZ should be used when physicians, practitioners, or suppliers want to indicate

that they expect that Medicare will deny an item or service as not reasonable and
necessary and they have not had an ABN signed by the beneficiary.
Addressing Misinformation Regarding Chiropractic Services and Medicare
I. Background
This fact sheet was developed by the CMS to correct misinformation in the Chiropractic
community relating to Medicare and its regulations as they relate to Chiropractic services. This
fact sheet is informational only and represents no changes to existing Medicare policy.
In order to correct misinformation about Medicare and its regulations which exist in the
Chiropractic community, the American Chiropractic Association (ACA) works to check the
validity of all claims and provide accurate information based on the Medicare manual system
maintained by the CMS, as well as information in regulatory and statutory language. The CMS
is providing this fact sheet which it hopes will clarify certain issues, around which there may be
some confusion.
II. Specifically Addressed Issues

Misinformation #1: There is a 12 visit cap or limit for Chiropractic services.
Correction: 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 at
www.cms.hhs.gov/manuals/IOM/list.asp on the CMS Web site. 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.
Misinformation #2: If you are a non-participating provider, you do not have to worry about
billing Medicare.
Correction: Being non-participating does not mean you don’t have to bill Medicare. All
Medicare covered services must be billed to Medicare, or the provider could face penalties.
A non-participating provider is actually a provider involved in the Medicare program who

has enrolled to be a Medicare provider but chooses to receive payment in a different
method and amount than Medicare providers classified as participating. Non-participating
providers may receive reimbursement for rendered services directly from their Medicare
patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the
portion of the charges for which Medicare is responsible. It is important to note that non-
participating providers may choose to accept assignment; therefore, the amount paid by the
beneficiary must be reported in Item 29 of the CMS 1500 claim form or its electronic
equivalent. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare
sending payment to the provider. Whether or not non-participating providers choose to
accept assignment on all claims or on a claim-by-claim basis, their Medicare
reimbursement is five percent less than a participating provider, as reflected in the annual
Medicare Physician Fee Schedule.
You can find a copy of the Medicare Participating Provider Agreement at

www.cms.hhs.gov/cmsforms/downloads/cms460.pdf (PDF, 104 KB) on the CMS Web site.
The form contains important information regarding the participation process and the annual
opportunity you have to make or change your participation decision.
Additional information is available on the CMS Web site

Medicare Benefit Policy Manual (Chapter 15; Covered Medical and Other Health Services)
at www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf (PDF, 1.12 MB)
Medicare Claims Processing Manual (Chapter 12; Physician/Nonphysician Practitioners) at
www.cms.hhs.gov/manuals/downloads/clm104c12.pdf (PDF, 903 KB)
Misinformation #3: If you are a non-participating provider, you will never be audited nor have
claims reviewed, etc.
Correction: Any Medicare claim submitted can be audited or reviewed. The non-
participating or participating status of the physician does not affect the possibility of this
occurring. The CMS audits/reviews are intended to protect Medicare trust funds and also to
identify billing errors so providers and their billing staff can be alerted of errors and
educated on how to avoid future errors. Correct coverage, reimbursement, and billing
requirements are readily available to assist you in understanding Medicare requirements.
This information is in Medicare manuals that are at www.cms.hhs.gov/Manuals/ on the

CMS Web site. In addition, an excellent way to stay informed about changes to Medicare
billing and coverage requirements is to monitor MLN Matters Articles, which are available at
www.cms.hhs.gov/MLNMattersArticles/ on the same site.
Misinformation #4: You should get an ABN signed once for each patient and it will apply to all
services and all visits.
Correction: 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 ABN then allows the beneficiary to
make an informed decision about receiving and paying for the service. Should the
beneficiary decide to receive the service, you must then submit a claim to Medicare even
though you expect the beneficiary to pay and you expect that Medicare will deny the claim.
For further information, see Chapter 30 of the Medicare Claims Processing Manual at
www.cms.hhs.gov/manuals/downloads/clm104c30.pdf (PDF, 1.19 MB) and Chapter 15 of
the Medicare Benefit Policy Manual at
www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf (PDF, 1.12 MB) on the CMS Web
site.
Misinformation #5: Maintenance care is not a covered service under Medicare.
Correction: Spinal manipulation is a covered service under Medicare, no matter which

phase of care you may be in; however, maintenance care is not medically reasonable and
necessary and therefore not reimbursable by Medicare. Acute, chronic and maintenance
adjustments are all covered services, but only acute and chronic services are considered
active care and may therefore be reimbursable. Per Chapter 15, Section 30.5.B. of the
Medicare Benefit Policy Manual, 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.
Misinformation #6: Non-participating providers do not have the same documentation

requirements as par providers.
Correction: Chiropractic care has documentation requirements to show medical necessity.

The participating status of the provider is irrelevant to the documentation requirements.
The National Correct Coding Initiative (NCCI)
I. What is the NCCI?

The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct
coding methodologies and to control improper coding leading to inappropriate payment in Part
B claims. The CMS annually updates the National Correct Coding Initiative Coding Policy
Manual for Medicare Services, which is known as the NCCI edits. The purpose of the NCCI
edits is to prevent improper payment when incorrect code combinations are reported.
The HCPCS/CPT code(s) used by chiropractors may be subject to Correct Coding Initiative
(CCI) edits (www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopofPage). Local
Coverage Determinations do not take precedence over CCI edits. Please refer to the CCI for
correct coding guidelines and specific applicable code combinations prior to billing Medicare.
II. Medicare Appeals

If you are dissatisfied with an initial Medicare claim determination, you have the right to request
an appeal. There are several appeal levels and each level must be processed before
proceeding to the next level.
To file an appeal, as for all providers and specialties, the steps and forms are found on the
Palmetto Web site at
www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Providers~Jurisdiction%201%20Part%
20B~Resources~Appeals?open
To help you decide whether you should reopen a claim or start the appeals process, please
read the two definitions below. The redetermination step is the first phase of filling an appeal.
Reopening
A remedial action taken to change a final determination or decision that resulted in an
overpayment or an underpayment. Reopenings are separate and distinct from the Appeal
process. Reopenings are discretionary on the part of the contractor. A contractor’s decision to
reopen a claim determination is not an initial determination and therefore, can not be appealed.
Redetermination
A Redetermination is the first level of appeal after the initial determination on Part A and Part B
claims. It is a second look at the claim and supporting documentation and is made by a
different contractor employee than the one who made the initial claim determination.
Using the Redetermination/Reopening Request Form

To reduce the number of incorrectly submitted redetermination requests and avoid
unnecessary delay in forwarding requests to the proper department, we strongly encourage
providers to use our revised Part B Redetermination/Reopening Request Form on our Web
site at The Revised Part B Redetermination/Reopening Request Form (PDF, 124 KB). You can
also access the form by clicking on the Forms link in the Self Service Tools and Top Links
section of the J1 Part B home page.
Once the processing of your claim is completed, you have the right to request a
redetermination if you disagree with the initial claim decision. The revised Part B
Redetermination/Reopening Request Form includes all required elements of a valid
request. Besides the specific state/region check boxes added to the top of the form, the
revised form also offers an easier flow of information and a comprehensive list of correct
mailing addresses to send your request. Using this form will allow us to identify your request
and forward it to the appeal department for processing in a timely manner.
Note: We do not accept requests electronically at this time. Please print and mail the
completed form to the correct mailing address. While it is not necessary to send copies of
Local Coverage Determinations (LCDs), any other supporting documentation should be
included with your redetermination request.
Fee Schedules
The following links will guide you to the current J1 Part B fee schedules for your region. Please
check the Palmetto GBA Web site periodically for fee schedules updates.
Northern California
www.palmettogba.com/palmetto/providers.nsf/DocsCat/Jurisdiction%201%20Part%20B~Public
ations~Fee%20Schedules~Medicare%20Physician%20Fee%20Schedules%20and%20Update
s~8525746A00550AA3852576A20057E99C
Southern California
s~8525746A00550AA3852576A200580C65
Nevada
s~8525746A00550AA3852576A10070BB5C
Hawaii, Guam, American Samoa and Marianna Islands

s~8525746A00550AA3852576A10070E5BB
Participating versus Non Participating Provider
I. Enrolling in the Medicare Program

Physicians, non-physician practitioners, and other health care suppliers must enroll in the
Medicare program to be eligible to receive Medicare payment for covered services provided to
Medicare beneficiaries.
The Medicare enrollment application is used to collect information about you and to secure the
necessary documentation to ensure you are qualified and eligible to enroll in the Medicare
program. Suppliers, other than suppliers of Durable Medical Equipment, Prosthetics, Orthotics,
and Supplies (DMEPOS), use three different enrollment application forms to enroll or change
their Medicare enrollment information:
 CMS-855I form: Medicare enrollment application used by individual physicians or non-
physician practitioners to initiate the Medicare enrollment process or to change their
Medicare enrollment information
 CMS-855B form: Medicare enrollment application used by clinics, group practices or other
organizational suppliers, except DMEPOS suppliers, to initiate the Medicare enrollment
process or to change their Medicare enrollment information
 CMS-855R form: Medicare enrollment application used to initiate a reassignment of a right
to bill the Medicare program and receive Medicare payments
Note: only individual physicians and non-physician practitioners can reassign the right to bill
the Medicare program
II. The Participation Program

A new provider/entity wishing to be listed as a participating provider within the Medicare
program must submit a completed participation agreement (CMS-460). A participating provider
must accept assignment on all Medicare claims. A signed participation agreement is not part of
the CMS 855 provider enrollment application. The CMS-460 is an additional form contract.
Once a new provider/entity has received notice of their Medicare Provider Identification
Number (PIN), they have 90 days from the date given on the approval letter to submit a signed
participation agreement to the Medicare carrier. If you choose to submit a participation
agreement, the effective date of your participation will be the date the agreement is received
by Medicare. Otherwise, the provider must wait until the annual open participation enrollment
period conducted by the CMS (CMS). At that time, a special participation agreement (CMS-
460) is mailed to all providers along with instructions for the annual participation enrollment
process via CD-ROM.
III. The Annual Open Participation Enrollment Period

Once a year, under the direction of the CMS, all providers are mailed an Annual Open
Participation Enrollment Package for the next calendar year. During this period, providers can
change their current participation status. This is the only time providers are given the
opportunity to change their participation status.
This participation enrollment package usually contains:

 Participation Announcement, the advantages of participation and what to do
 A Fact Sheet/CMS Medicare Learning Network (MLN) article (proposed legislative
changes, which could impact the participation decision)
 Medicare Fee Schedule allowances for the next calendar year
 The Participating Provider Agreement form, (CMS-460). If you are already a participating
provider, it is not necessary to sign another agreement. The current participation status will
remain in effect until the carrier is notified otherwise. A change in legal identity will require a
new participation decision. You must submit a new Participating Provider Agreement form
in these instance
IV. What Is Participation?

In Medicare, “participation” means you agree to always accept assignment of claims for all
services you furnish to Medicare beneficiaries. By agreeing to always accept assignment, you
agree to always accept Medicare-allowed amounts as payment in full and to not collect more
than the Medicare deductible and coinsurance from the beneficiary. Unlike many private
insurance plans, the Social Security Act requires you to submit claims for Medicare
beneficiaries whether you participate or not.
V. Benefits of Participation
If you decide to participate in the Medicare program as a participating supplier, submit a
participation agreement, using the “Medicare Participating Physician or Supplier Agreement,”
(Form CMS-460). It should be submitted simultaneously with the Medicare enrollment form.
Although you have up to 90 days to submit the agreement, your physician benefits will not start
until the agreement is submitted. There is a CMS annual enrollment period, which is generally
conducted in November.
The benefits of Medicare participation include:

 Medicare reimbursement is 5 percent higher than it is for those who do not participate
 Medicare payments are issued directly to the physician/supplier because the claims are
always assigned
 Claim information is forwarded to Medigap (Medicare supplemental coverage) insurers
VI. Assigned Claims

When a physician files an assigned claim to the Medicare Part B carrier, the reimbursement is
sent directly to you, the provider. You agree to accept the Medicare fee schedule amount as
payment in full for all covered services and will only collect non-covered services, any unmet
deductible and any co-pay amount from the beneficiary.
Assignment is not automatic on a claim unless you have completed the 'Participating Physician
Agreement.” Otherwise, you must check the appropriate block (27) of the CMS-1500 (12-90)
claim form or the applicable electronic claim field to accept assignment of Medicare benefits for
that claim. While the provider can be non-participating with the Medicare Part B carrier, he/she
may still accept assignment on a particular claim. If the claim is filed as assigned, you must
follow the rules of the assignment agreement, and may not collect more than the Medicare fee
schedule for the covered services.
VII. Nonassigned Claims

When a claim is filed as nonassigned, the Medicare Part B carrier sends the reimbursement
directly to the patient/beneficiary. You must check the appropriate block (27) of the CMS-1500
(12-90) claim form or the applicable electronic claim field to indicate that you are not going to
accept assignment of Medicare benefits for that claim. Only a non-participating Medicare
provider can file a claim nonassigned.
If you are a non-participating physician, you have a choice to file a claim assigned or
nonassigned. If you choose to file the claim nonassigned, you may only collect from your
patients up to the limiting charge (discussed at the end of this chapter) of a covered Medicare
Part B service, as well as your established fee for any non-covered services.
VIII. Opting Out of Medicare

For Doctors of Chiropractic, opting out of Medicare is not an option. Note that opting out and
being non-participating 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) on the CMS Web site at
www.cms.hhs.gov/manuals/downloads/bp102c15.pdf (PDF, 1.12 MB).
Comprehensive Error Rate Testing (CERT) Program
The CERT program measures the accuracy of Medicare claims with two types of error rates:
paid claims error rate and provider compliance error rate.
Paid Claims Error Rate measures the percentage of incorrect payments and dollar amount
incorrectly paid
Types of Errors:
• Improper documentation
• Insufficient documentation
• Medically unnecessary
• Incorrect coding
• Service billed was not rendered
• No response to the CERT Contractor’s request for medical records
CERT Paid Claims Error Rates for Palmetto GBA

May 2008 Report: Five Highest Code Groups
30.0%
24.2%
25.0%
19.6%
20.0%
15.0%
12.1% 11.6%
9.3%
10.0%
5.0%
0.0%
Chiropractic Consultations Hospital visits- Office visits- Other tests
services subsequent new
Provider Compliance Error Rate measures the accuracy of submitted claims.

 It is based on how claims looked when they first arrived at Palmetto GBA, therefore, it
reflects how effectively the Contractors educate providers (Most recent data available: May
2008).
o Across multiple specialties
o Involving various categories of provider inquiries and claim denials
• Data on specific types of errors are unavailable
• We use other sources such as the top inquiry reasons and top denial reasons to focus our
education efforts
Provider Compliance Error Rates
45.00%
40.00%
35.00% 40.5%
30.00%
25.00%
All Specialties
20.00% 25.5%
Chiropractic
15.00% 18.8%
15.7%
10.00%
5.00%
0.00%
NOV 07 MAY 08
Recovery Audit Contractor (RAC)
I. What is RAC?
The Medicare Modernization Act (MMA) of 2003 requires the use of Recovery Audit
Contractors (RACs) to:
 Review paid claims to ensure they meet Medicare statutory, regulatory and policy
requirements and regulations
 Analyze billing trends and patterns
 Identify Medicare over/underpayments
 Recoup overpayments
Claims are reviewed on a post-payment basis. The RACs use the same Medicare policies
such as NCDs, LCDs and CMS Manuals as Carriers, FIs and MACs.
There are two types of RAC review:

 Automated (no medical record needed)
 Complex (medical record required)
II. Contact J1 RAC Health Data Insight, Inc.

Web site: http://racinfo.healthdatainsights.com
E-mail: racinfo@emailhdi.com
Phone: (866) 376-2319 for Part B
III. RAC Contractor Reviews

 Review of physician claims for level of coding
 Authorized to look back three years from the date the claim was paid
 Initially RAC will not go beyond October 1, 2007
 RAC will review claim history and request medical records
 Providers will have 45 days to submit records
IV. 2009 Medical Record Limits

 Medical request limits in place for Physicians, Podiatrists, and Chiropractors
o Sole Practitioner: 10 medical records per 45 days per NPI
o Partnership 2-5 individuals: 20 medical records per 45 days per NPI
o Group 6-15 individuals: 30 medical records per 45 days per NPI
o Large Group 16+ individuals: 50 medical records per 45 days per NPI
V. What is different?
 If an overpayment is detected, the RAC will pursue payment
 Overpayment/demand letter is issued by the RAC
 RAC will offer an opportunity for the provider to discuss the improper payment
determination (this is outside the normal appeal process)
 Issues reviewed by the RAC will be approved by the CMS prior to widespread review
 Approved issues will be posted to a RAC Web site before widespread review
VI. Prepare for Implementation

 Know identified “risk areas” for improper payments
 Review OIG and CERT reports
o www.oig.hhs.gov/oas/cms.asp and www.cms.hhs.gov/CERT
 Appoint a specific person for RAC to contact and provide
o Name
o Complete address
o Phone
o Fax
o E-mail address
 Respond to medical record requests fully and promptly
 Track dates and number of requests received
 Conduct an internal assessment to identify whether you are in compliance with Medicare
rules
 Learn from experience
o Keep track of denied claims and look for patterns
o Determine actions needed to avoid improper payments
VII. RAC Resources at the CMS Web site www.cms.hhs.gov/RAC/

 Overview of program
 Strategy to expand the RAC program
 Press releases
 Frequently Asked Questions (FAQs)
Chiropractic Specialty Resources
 Local Coverage Determination (LCD) at Palmetto GBA J1 Part B Web site>Medical

Policies> LCDs and NCDs
 Chiropractic Misinformation: MLN Matters; MLN matters article SEO749

www.cms.hhs.gov/MLNMattersArticles/downloads/SE0749.pdf (PDF, 89 KB)
 Signature requirements
www.palmettogba.com/Palmetto/Providers.nsf/files/J1_Medicare_Advisory_September_We
b.pdf/$FIle/J1_Medicare_Advisory_September_Web.pdf (PDF, 2.54 MB)
 Specific details regarding documentation: Medicare Benefit Policy Manual (Chapter 15,
Sections 30.5 and 240) at www.cms.hhs.gov/manuals/downloads/bp102c15.pdf (PDF, 1.12
MB)on the CMS Web site
 Also, see the Medicare Claims Processing Manual (Chapter 12, Section 220) at
www.cms.hhs.gov/manuals/downloads/clm104c12.pdf (PDF, 902 KB) on the CMS Web site
 J1 Part B Web site www.PalmettoGBA.com/j1b

o Fee schedules
o Information for your Medicare patients
 Medicare Advisory posted in the Publications section of the J1 Part B Web site
 CMS manuals at www.cms.hhs.gov/manuals
o 100-01, Chapter 5, section 70.6 (chiropractor definition)
o 100-02, Chapter 15, section 30.5 (coverage)
o 100-02, Chapter 15, section 240 (necessity for treatment)
o 100-04, Chapter 12, section 220 (documentation requirements)
 American Chiropractic Association

1701 Clarendon Blvd.
Arlington, VA 22209
Phone: (703) 276-8800
Contact Us
J1 Part B Important Addresses, Telephone Numbers and Fax Numbers
Department Contact Information
J1 MAC - Palmetto GBA

P.O. Box 1051
Augusta, GA 30903-1051
Hawaii/Nevada
Fax: (803) 462-3932
Claims Northern California

Fax: (803) 462-3930
Southern California
Fax: (803) 462-3931
Note: The fax numbers are for additional information to

accompany electronically-submitted claims only.
J1 A/B MAC - Palmetto GBA

Electronic Data P.O. Box 100145
Interchange (EDI) Columbia, SC 29202-3145
Telephone: (866) 749-4301
Electronic Funds E-mail: EFT.Admin@PalmettoGBA.com

Transfer (EFT) Telephone: (866) 749-4301
J1 MAC - FOIA Coordinator

Freedom of Palmetto GBA
Information Act (FOIA) P.O. Box 1091

General P.O. Box 1091
Correspondence Augusta, GA 30903-1091
Fax: (803) 462-3912
J1 Technical Support
for Electronic Billing,
Telephone: (866) 749-4301
Electronic Remittance
Fax: (803) 870-8035
Advice (ERA) and other
EDI Issues

P.O. Box 1476
Medical Review
ADR Fax: (803) 462-3929
General Correspondence Fax: (803) 462-3918
Medicare BCC
General Written Correspondence
Medicare Beneficiary
P.O. Box 39
Call Center
Lawrence, KS 66044
All questions related to
the Medicare program
Telephone: (800) 633-4227
TTY: (877) 486-2048
Medicare Secondary J1 MAC - Palmetto GBA

Payer P.O. Box 1687
Fax: (803) 462-3922
CSR: (866) 931-3901

Provider Contact IVR: (866) 931-3903
Center (PCC) TTY: (866) 931-3902
E-mail: J1PCC.Contact@PalmettoGBA.com

P.O. Box 1508
Provider Enrollment
Note: Complex Inquiries Only Telephone: (866) 895-1520. This
number is not for status updates.
Provider Outreach and J1 MAC - Palmetto GBA

Education P.O. Box 2166
Requests for workshops Augusta, GA 30903-2166
or meeting only Fax: (803) 763-2280

Redeterminations and
P.O. Box 1252
Reopenings
Make telephone
corrections to submitted
Telephone Reopenings (restrictions apply):
claims
(866) 669-5543
Overnight Delivery
Address
2743 Perimeter Parkway
Bldg 200 - 2nd Floor
Augusta, GA 30909

Part B Accounts Receivable
P.O. Box 1416
Overpayments Northern California

P.O. Box 250
Southern California
P.O. Box 550
This checklist is a tool to help make sure you have included all the documentation required to submit your
claim correctly. Have you recorded the necessary components of an initial or subsequent visit? Which
parts of the spine did you treat? Are you billing the correct code – and HCPCS modifier? Refer to
www.PalmettoGBA.com/bsc, “Chiropractic” for more help.
Chiropractic Billing and Documentation Checklist

*Beneficiary Name: *HICN:
*DOS:
*All Records for 1 Bene? Yes No
Diagnosis: Initial visit(s)?: Yes No Subsequent visit(s)?: Yes No
CPT Code Billed:

98940 Chiropractic manipulation, 1-2 regions AT Modifier Present? Yes No
98941 Chiropractic manipulation, 3-4 regions GA Modifier Present? Yes No
98942 Chiropractic manipulation, 5 regions
98943 Chiro manipulation (not payable by Medicare)
Correct Beneficiary? Yes No Correct Dates of Service? Yes No Valid Physician Signature? Yes No
Acute Condition: Yes No Chronic Condition: Yes No

Accident Injury Fall Other Date: Date of Exacerbation:
Date of Recurrence:
Documentation Requirements
Initial Subsequent
DOS Billed:
Is the following documentation present? Yes No Is the following documentation present? Y N Y N Y N
Diagnosis of subluxation Diagnosis of subluxation
Subluxation identified through physical exam History (review of chief complaint,
or x-ray NOTE: If physical exam – must meet changes since last visit and system review
requirements (P_A_R_T) if relevant)
History Physical Examination
Description of present illness Documentation of treatment given on day
of visit
Symptom(s) Level(s) of treatment
Evaluation Contraindication(s) present?
Treatment Plan Services reasonable and necessary?
Date of initial treatment
Level(s) of treatment
Contraindication(s) present?
Services reasonable and necessary?
Subluxation Documentation: Spinal Areas/Vertebrae

Area of Spine Name of Vertebrae Treated Area(s)
Neck Occiput (Occ,CO), Cervical (C1-C7), Atlas (c1), Axis (2)
Back Dorsal (D1-D12) or Thoracic (T1-T12), Cost vertebral (R1-
R12), Cost transverse (R1-R12)
Low Back Lumbar (L1-L5)
Pelvic Iliac bones (R and L) (I, Si)
Sacral Sacrum, Coccyx (S, SC)
Remarks:
All CPT codes, descriptors and other data only are copyright 2009 American Medical
Association (or such other date of publication of CPT). All Rights Reserved. Applicable
FARS/DFARS Apply. All CPT Codes and indications are noted where applicable.
Print Form
Comprehensive Error Rate Testing (CERT)
Part B Chiropractic Checklist
This claim was selected for review by the CERT contractor. You will have 75 calendar days to submit
the requested information from the date of the original request for medical records. Please use the
fax number or the mailing address given in the CERT contractor letter when submitting the requested
documentation. The documentation should include, but is not limited to:
Name of beneficiary and date of service on all documentation
Initial history
Diagnosis of subluxation
Beneficiary's specific complaint
Treatment plan, which should include:
Therapeutic modalities
Frequency and duration of visits
Specific goals that are to be achieved with treatment
Objective measures to evaluate treatment progress
Description of present illness, which should include:
Mechanism of trauma
Symptoms causing beneficiary to seek treatment
Onset, duration and intensity of symptoms
Aggravating or relieving factors
Prior interventions, treatments and medications
Physical examination findings, which should include:
Specific abnormal findings
Pain detailing location quality and intensity
Impairments in range of motion
Precise level of subluxation
Daily treatment notes
Change in beneficiary's condition
Documentation indicating regions of the spine where manipulation was performed
Documentation to support that the services billed were reasonable and necessary
Documentation includes appropriate signatures and contact information
If using electronic medical records/signatures include documentation validating the process
Revised 7-2009

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I. Licensure and Authorization to Practice

Chiropractors Licensed or Authorized to Practice Prior to July 1, 1974

II. Chiropractic Coverage Guidelines

Frequency of Chiropractic Visits

Coverage of Chiropractic service is specifically limited to treatment by means of manual

No other diagnostic or therapeutic service furnished by a chiropractor or ordered by a

III. What is Subluxation?

IV. Demonstrating Subluxation

There is no requirement for chiropractors to obtain X-rays prior to treatment. If subluxation is

• X-ray at each level of subluxation

Manual Manipulation Synonyms

Manipulation is not covered when:

What is Maintenance Therapy?

I. Initial Visit Documentation

 Present Illness: This can include any of the following as appropriate

 Physical Examination: Evaluation of the musculoskeletal/ nervous system through

 Treatment Plan: The treatment plan should include the following

Sample Treatment Plan

Short term goals

Long term goals

II. Subsequent Visit Documentation

Sample Subsequent Note

Documentation and Medical Review

I. Why Is Documentation Important?

“Abbreviations: A Shortcut to Disaster” by Fay Yocum, MSN, RN

II. Purpose of Medical Records

III. Legal Signature Must Be Identifiable and Legible

IV. Illegible Documentation and Graphs

Illegible Handwriting: What is this order for?

V. Use of Specialty Jargon

VI. The Use of Check Lists

VII. The Establishment of Patient Goals

VIII. Maintenance Therapy Is Not A Covered Benefit

IX. Treatment Must Be Reasonable and Necessary

X. The Regions and Levels Treated Must Be Identified

XI. Date of Service Not Identified

Make sure that you:

XII. Medical Record Review

XIII. How to Avoid Documentation Pitfalls

XIV. Local Coverage Determination

I. Frequency of Chiropractic Visits

II. Applicable CPT/HCPCS Codes

* CPT code 98943 is not a Medicare benefit.

III. ICD-9-CM Codes that Support Medical Necessity

Required Primary ICD-9-CM Codes (Names of Vertebrae)

Required Secondary ICD-9-CM Codes

IV. Special Requirements for Chiropractic Claims

VI. Modifier Use

* Please refer to the Limitation of Liability (Advance Beneficiary Notice of Noncoverage)

VII. Remittance Advice Guide (RA)

VIII. Common Claim Denials

Patient Responsibility (PR) Contractual Obligation (CO)

Missing Claims Data

Medically Unnecessary Services

Services Incorrectly Coded

Limitation of Liability (Advance Beneficiary Notice of Noncoverage)

I. Advanced Beneficiary Notice (ABN)

Examples of when you should ask the patient to sign an ABN:

II. ABN Modifiers

 Modifier GY should be used when physicians, practitioners, or suppliers want to indicate

 Modifier GZ should be used when physicians, practitioners, or suppliers want to indicate