Expansion of Coverage for
Chiropractic Services Demonstration (MMA)Available as a Word Document
Billing rules from this whole article are summed up here: (updated 5-21-2005)
(These rules are for Illinois, although it "should" be the same for all the demo sites:
of a CMS1500 form or in the ASCX12837 electronic format, you should report the demonstration number in the 2300/REF loop. In addition to demo 45, you MUST have the date last seen (or assessed) and UPIN of attending physician. So Box 19 must be "demo 45 xx/xx/xxxx U12345" but with dates and correct UPIN of coarse. PLEASE DO NOT MAKE THE MISTAKE, a UPIN is different then a PIN. Put the UPIN in Box 19.
Billing for the CMT (98940-42) will be the same rules as before the project (that is, the CMT codes must have the -AT modifier (active therapy), or it will be rejected as "maintenance care")
Billing Demonstration project codes – you must put them on a separate claim form and you must use the diagnosis codes listed in this article. So when you are billing for demo codes PLUS CMT you will use 2 different claim forms.
You must put "demo 45" in box 19
Box 17 - Must have referring doctors name or if there is no referring, put attending/ordering doctors name
Box 17A - Must have UPIN of referring/attending doctor
You must use AT modifier on ALL codes that are active treatment and not maintenance care.
You must put an AT & GP modifier on all Physical therapy codes (excluding 64550)
You must put an AT & 25 modifier on all E & M codes (office visits)
You must put an AT modifier on the CMT codes
Have a new plan of care every 30 days (following the re-exam)
Change Box 14’s dates according to description below from the CMS guidelines (see page 3)
Make sure your documentation is in order to back up all the procedures you do, everything has to be documented or it wasn’t done.
The Use of CPT Modifiers:
= Active Therapy AT
GP = Identifies it as a Physical Therapy (PT) covered under the demonstration project
GY= a non-covered service. If you supply PT to a patient in a non-demonstration project area, you still want Medicare to know that chiropractors provide this type of service. You must also signify that the patient knows Medicare won't be paying for it with the GY modifier.
GA = is a REQUIRED modifier that MUST be used whenever you have an ABN signed
GZ = is an optional, although strongly recommended, modifier that signifies
you know you should have had an ABN signed but, for some reason, did not.
-25 = Significant, separately identifiable E&M service, provided by the same physician on the same day as another procedure which also contains a pre- and post-treatment assessment.
-51 = Multiple Procedures modifier
-52 = Reduced Services Modifier
-59 = Distinct Procedural Service This advises that the second service was distinct or separate from other services performed on the same day.
Provider Types Affected
Chiropractors who practice in the States of Maine and New Mexico, Scott County, Iowa, 26 counties in Illinois (including Cook, DeKalb, DuPage, Grundy, Kane, Kendall, McHenry, Will, Boone, Bureau, Carroll, Henry, JoDaviess, Kankakee, Lake, LaSalle, Lee, Marshall, Mercer, Ogle, Putnam, Rock Island, Stark, Stephenson, Whiteside, and Winnebago counties), and 17 counties in central Virginia (including Pittsylvania, Campbell, Appomattox, Nelson, Buckingham, Fluvanna, Louisa, Caroline, Hanover, New Kent, Henrico, Richmond City, Danville City, Goochland, Cumberland, Powhatan, and Amelia counties).
Provider Action Needed
Under a two-year demonstration project beginning April 1, 2005, doctors of chiropractic will be able to bill Medicare carriers for the Part B medical, radiology, clinical lab, and therapy services that they provide for their Medicare fee-for-service patients. These services must be billed separately from current services that are covered under Medicare. You must include a demonstration code for all demonstration claims.
Under this demonstration, doctors of chiropractic will also be allowed to bill Medicare for CPT code 98943—extraspinal manipulation. The fee amounts for 98943 per geographic area can be found in Table 1 of this article. Coverage will also be expanded to include other ancillary services chiropractors are legally allowed to provide and Medicare currently covers. These procedures include electrotherapy, ultrasound, TENS therapy, and other services that are medically necessary for the treatment of neuromusculoskeletal conditions. Chiropractors will be allowed to provide physical therapy services and to refer patients for therapy under this demonstration.
Chiropractors will also be reimbursed for Evaluation and Management (E&M) services delivered for neuromusculoskeletal conditions. Under the demonstration, chiropractors will be allowed to bill Medicare for both an E&M visit and for treatment the first time you assess a patient, as well as for current patients in instances such as when there is a new condition, exacerbation or recurrence of the current condition, or for a reassessment midway through treatment.
Chiropractors should not bill for an E&M service every time they treat a patient. Chiropractors billing Medicare under this demonstration must follow the same documentation guidelines that physicians follow for E&M services.
For example, chiropractic manipulation codes include a brief pre-manipulation patient assessment. Additional E&M services may be reported separately using the modifier "-25" if, and only if, the patient’s condition requires a significant separately identifiable E&M service. When manipulation and E&M codes are billed for the same visit, it is necessary to attach a "-25" modifier to the E&M code. These guidelines can be found at:
http://www.cms.hhs.gov/medlearn/emdoc.asp
Additional E&M guidance can also be found in the Medicare Claims Processing Manual, publication 100- 04, Chapter 12, Section 30. This manual may be accessed at:
http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp
Services provided under this demonstration must be related to acute or active treatment, not maintenance or prevention of neuromusculoskeletal conditions. You must place an AT modifier next to every CPT code on all claims when providing active/corrective treatment to treat acute or chronic subluxation.
You should be aware that while under this demonstration, chiropractors will be subject to the same coverage and payment rules that physicians and physical therapists must follow, such as:
rules that apply to physicians regarding billing for the delivery of E&M services and treatment in the same visit;
coinsurance or deductible rules; and 3) rules regarding the delivery of physical therapy services, including identifying these services using the GP modifier, and certifying the plan of care every 30 days. These requirements can be found in the Medicare Benefit Policy Manual 100-2 in Chapter 15, Sections 220 and 230 and the Medicare Claims Processing Manual 100-4 in Chapter 5, Section 20 and other manual sections.
The Medicare Benefit Policy Manual may be found at:
http://www.cms.hhs.gov/manuals/102_policy/bp102index.asp
In addition, chiropractors must follow physician rules for providing therapy services under the "incident to" provision of the physician regulation. When a physical therapy service is provided incident to the service of a chiropractor, the person who furnishes the service must meet the standards and conditions that apply to physical therapists, except that a license is not required.
This means that unless chiropractic students, chiropractic assistants, or sports trainers have graduated from a physical therapy curriculum approved by:
1) the American Physical Therapy Association, or 2) The Committee on Allied Health Education and Accreditation of the American Medical Association, or 3) the Council on Medical Education of the American Medical Association and the American Physical Therapy Association, they cannot provide therapy services incident to a chiropractor. The only exception is that certain persons trained prior to January 1, 1966 may be grandfathered (see 42 CFR 484.4).
Finally, you should check your local Medicare carrier website for information on local coverage decisions regarding demonstration services.
Rules from this whole article summed up:
Billing for the CMT (98940-42) will be the same rules as before the project
Billing Demonstration project codes – you must put them on a separate claim form and you must use the diagnosis codes listed in this article. So when you are billing for demo codes PLUS CMT you will use 2 different claim forms
You must put "demo 45" in box 19 of a CMS1500 form or in the ASCX12837 electronic format, you should report the demonstration number in the 2300/REF loop
You must use AT modifier on ALL codes that are active treatment and not maintenance care.
You must put an AT & GP modifier on all Physical therapy codes (excluding 64550)
You must put an AT & 25 modifier on all E & M codes (office visits)
You must put an AT modifier on the CMT codes
Have a new plan of care every 30 days
Change Box 14’s dates according to description below from the CMS guidelines
Make sure your documentation is in order to back up all the procedures you do, everything has to be documented or it wasn’t done.
Box 14:
Enter either an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) date of current illness, injury, or pregnancy. For chiropractic services, enter an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) date of the initiation of the course of treatment.
Therefore if a patient comes in with a neck injury on Monday June 2, 1999 you will put 06/02/1999 in box 14, BUT then if she comes back on June 5th, 1999 with a lower back pain, you would change the date in box 14 to 06/05/1999.
CPT codes that are covered under the demonstration project:
Code Chiropractic Manipulation Codes
98940 manipulation 1-2 regions
98941 manipulation 3-4 regions
98942 manipulation 5 regions
98943 New for demo--extraspinal manipulation
Code Evaluation and Management Codes
99201 New patient 10 minutes
99202 New patient 20 minutes
99203 New patient 30 minutes
99204 New patient 45 minutes
99205 New patient 60 minutes
99211 Established patient 5 minutes
99212 Established patient 10 minutes
99213 Established patient 15 minutes
99214 Established patient 25 minutes
99215 Established patient 40 minutes
Code Diagnostic Codes
95831 Muscle testing, manual with report; extremity or trunk
95832 Hand, with or without comparison with normal side
95833 Total evaluation of body, excluding hands
95834 Total evaluation of body, including hands
95851 Range of motion measurements and report; each extremity or each trunk section
95852 Hand, with or without comparison with normal side
95857 Tensilon test for myasthenia gravis
95858 With electromyographic recording
95860 Needle electromyography; one extremity with or without related paraspinal areas
95861 Two extremities with or without related paraspinal areas
95863 Three extremities with or without related paraspinal areas
95864 Four extremities with or without related paraspinal areas
95867 Cranial nerve supplied muscles, unilateral
95868 Cranial nerve supplied muscles, bilateral
95900 Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study
95903 Motor, with F-wave study
95904 Sensory
Code Therapy Codes
64550 Application of surface (transcutaneous) neurostimulator
97012 traction, mechanical
97018 paraffin bath
97020 Microwave
97024 Diathermy
97026 Infrared
97028 Ultraviolet
97032 electrical stimulation, constant attendance
97034 contrast baths
97035 Ultrasound
97039 unlisted modality
97110 therapeutic exercise
97112 neuromuscular reducation
97113 aquatic therapy with exercise
97116 gait training
97124 Massage
97139 unlisted therapeutic procedure
97140 Manual therapy techniques
97150 therapeutic procedures, group
97504 orthotic fitting and training
97530 Therapeutic activities--dynamic activities to improve functional performance
97703 check out for orthotics and prosthetic use
97750 physical performance test or measurement, with written report
97799 unlisted physical medicine/rehabilitation service
G0283 unattended electrical stimulation for other than wound care
Code X rays
72010 x-ray spine entire
72020 x-ray spine, 1 view
72040 xray spine cervical 2-3 views
72050 x-ray, spine cervical 4+ views
72052 x-ray spine cervical complete,
72069 x-ray spine standing for thoracolumbar
72070 x-ray spine thoracic 2 views
72072 x-ray spine thoracic 3 views
72074 x-ray, spine thoracic 4+ views
72080 x-ray spine thoracolumbar 2 views
72090 x-ray spine thoracolumbar supine and standing
72100 x-ray spine lumbosacral 2-3 views
72110 x-ray spine lumbosacral 4+ views
72114 x-ray spine lumbosacral complete
72120 x-ray spine lumbosacral bending only
72170 x-ray pelvis, 1-2 views
72190 x-ray pelvis complete
72200 x-ray sacroiliac joints, up to 3 views
72202 x-sacroiliac joints 3+ views
72220 x-ray sacrum and coccyx 2+ views
73000 x-ray clavicle complete
73010 x-ray scapula compete
73020 x-ray shoulder 1 view
73030 x-ray shoulder 2+ views
73050 x-ray acromioclavicular joint, bilateral
73060 x-ray humerus, 2+ views
73070 x-ray elbow 2 views
73080 x-ray elbow 3+ views
73090 x-ray forearm 2 views
73100 x-ray wrist, 2 views
73110 x-ray wrist, 3+ views
73120 x-ray hand 2 views
73130 x-ray hand 3+ views
73140 x-ray finger(s) 2+ views
73500 x-ray hip unilateral 1 view
73510 x-ray hip unilateral 2+ views
73520 x-ray hip bilateral 2+ views
73550 x-ray femur 2 views
73560 x-ray knee 1-2 views
73562 x-ray knee 3 views
73564 x-ray knee 4+ views
73565 x-ray bilateral knees standing
73590 x-ray tibia fibula 2 views
73600 x-ray ankle 2 views
73610 x-ray ankle 3+ views
73620 x-ray foot, two views
73630 x-ray foot, 3+ views
73650 x-ray heel 2+ views
73660 x-ray toe--2 or more views
71100 x-ray ribs, unilateral; 2 views
71110 x-ray ribs, bilateral 3 views
71120 x-ray sternum, 2+ views
71130 x-ray, sternum+sc joint
Make sure to put a AT modifier on ALL codes that are NOT maintenance care.
Diagnosis codes used with the demonstration project codes listed above.
Do not use these codes when billing for CMTs.
Medicare Demonstration Project Cheat Sheet Code Description Specific Codes Within the Range
307 Special symptoms 307.81
138 Late effects of poliomyelitis
340 Multiple sclerosis
346 Migraine 346.0, 346.1, 346.2, 346.8, 346.9
350 Trigeminal neuralgia 350.1, 350.2
352 disorder cranial nerve 352.4
353 disorder, nerve root and plexus 353.0, 353.1, 353.2, 353.4, 353.6
354 Mononeuritis, upper limb and multiple 354.0, 354.1, 354.2, 354.3, 354.4, 354.8, 354.9
355 Mononeuritis, lower limb 355.0, 355.1, 355.2, 355.3, 355.4, 355.5, 355.6, 355.71, 355.79, 355.8, 355.9
356 Neuropathy, hereditary and idoiopathic 356.1, 356.4, 356.8, 356.9
358 disorders myoneural 358.00, 358.01
715 Arthritis, osteoarthritis* 715.0x, 715.1x, 715.2x, 715.3x, 715.8x, 715.9x
716 Arthropathies, NEC/NOS* 716.1x, 716.2x, 716.3x, 716.4x, 716.5x, 716.6x, 716.8x, 716.9x
717 derangement, knee internal 717.0-3, 717.40-43, 717.49, 717.5-7, 717.81-84, 717.85, 717.89, 717.9
718 derangement, other joint* 718.0x, 718.1x, 718.6x, 718.8x, 718.9x, 718.48
719 disorder, joint NEC/NOS* 719.0x, 719.1x, 719.2x, 719.3x, 719.4x, 719.5x, 719.6x, 719.7x, 719.8x, 719.9x
720 Spondylitis, ankylosing and othe 720.0, 720.1, 720.2, 720.81, 720.89, 720.9
inflammatory spondylopathies
721 Spondylosis and allied disorders 721.0, 721.1, 721.2, 721.3, 721.4, 721.5, 721.6, 721.7, 721.8, 721.90, 721.91
722 disorder, intervertebral disc 722.0, 722.10-.11, 722.2, 722.30-.32, 722.39-.4, 722.51-.52, 722.6 722.70-.73, 722.81-.83, 722.91-.93
723 disorder cervical spine 723.0, 723.1, 723.2, 723.3, 723.4, 723.5, 723.6,
723 disorder cervical spine 723.7, 723.8, 723.9
724 disorders, back NEC/NOS 724.00-03, 724.1-6, 724.70, 724.71, 724.79, 724.8, 724.9
725 Polymyalgia rheumatica
726 enthesopathies, peripheral and allied syndromes 726.0, 726.10-.12, .19, 726.2, 726.30-.32, .39, 726.4, .5, 726.60-.65, .69, 726.70-.73.79,
726.8, .90, .91
727 disorders, synovium tendon and bursa 727.00-.06, 727.09,.1, .2, .3, 727.40-.43, 727.49, 727.50-.51, 727.59,728 disorders, muscle, ligament and fascia 728.10-.12, 728.2, .3, .4, .5, .6, 728.71, 728.79, 728.81, 728.83, 728.85, 727.60-.69, 727.81-.83, 727.89-.9 733 Other disorders of bone and cartilage 733.6, 733.92 728.87, 728.89, 728.9
735 deformity, toe acquired 735.0, 735.1, 735.2, 735.4, 735.5, 735.8, 735.9
736 Deformity, limbs acquired 736.00-.07, 736.09-.1, 736.20-.22, 736.29-.32, 736.39, 736.41-.42, 736.6,.70-.76, 736.79,737 Curvature spine 737.0, 737.10, 737.11, 737.12, 737.19, 737.20-22, 737.29, 737.30-34, 736.81, 736.89 738 deformity, acquired 738.2-9 737.40-43, 737.8, 737.9
739 Lesions, nonallopathic NEC 739.0-9
754 Congenital musculoskeletal deformities 754.1, 754.2, 754.40-44, 754.50-53, 754.59, 754.60-62, 754.69, 754.70, 754.71, 754.79
756 other congenital musculoskeletal abnormalities 756.10-15, 756.17, 756.19, 756.2, 756.3, 756.4, 756.82, 756.83, 756.89
840 Sprains and strains of shoulder and upper arm 840.1-9
841 Sprains and strains of elbow and forearm 841.0-.3,
842 Sprains and strains of wrist and hand 842.00-02, 842.09-13, 842.19
843 Sprains and strains of hip and thigh 843.0, 843.1, 843.8, 843.9
844 Sprains and strains of knee and leg 844.0-844.3, 844.8, 844.9
845 Sprains and strains of ankle and foot 845.00-03, 845.09-13, 845.19
846 Sprains and strains of the sacroiliac region 846.0-3, 846.8, 846.9
847 Sprains and strains of back NEC/NOS 847.0-4, 847.9
848 Sprains and strains, ill-defined, NEC 848.3, 848.40-42, 848.49, 848.8, 848.9
905 Late effects, musculoskeletal and 905.1-9
connective tissues injuries
907 Late effects, injuries to the nervous system 907, 907.1-5, 907.9
922 Contusion, trunk 922.1, 922.31, 922.33, 922.33, 922.8
923 Contusion, upper limb 923.00-03, 923.09-11, 923.20-21, 923.3, 923.8, 923.9
924 Contusion, lower limb 924.00, 924.01, 924.10-11, 924.20-21, 924.3-5, 924.8, 924.9
955 Injury, peripheral nerve(s) of shoulder 955.0-9
girdle and upper limb
956 Injury, peripheral nerve(s) of pelvic 956.0-5, 956.8, 956.9
girdle and lower limb
958 Certain traumatic complications 958.6
784 Symptoms involving head and neck 784
* = "x" specifies anatomic site, and any value would be appropriate
CMT DX CODES FOR MEDICARE ONLY USE THESE DX CODES ON CMT CODES (98940-42) ONLY SHORT TERM CARE MODERATE TERM CARE CONTINUED 307.81 Tension Headache 846.3 Sprain/Strain of sacrotuberus (ligament) 346.00. Classical migraine w/o intractable migrain 846.8 Sprain/Strain of sacrolic, other spec. sites 346.01 Classical migraine with intractable migrain 847.0. Sprain/Strain of neck 346.10. Common migraine w/o intractable migraine 847.1 Sprain/Strain of thoracic 346.11 Common migraine with intractable migraine 847.2 Sprain/Strain of lumbar 346.20. Variants of migraines w/o intract. migraine 847.3 Sprain/Strain of Sacrum 346.21 Variants of migraines with intract migraine 847.4 Sprain/Strain of Coccyx 346.80. Other forms of migraines w/o intract migrain 346.81 Other forms of migraines with intract migrain 346.90. Migraine, unspec w/o intractable migraine LONG TERM CARE 346.91 migraine, unspec with intractable migraine 721.7 Traumatic Spondylopathy 355.1 Meralgia paresthetica 722.0 Displmt of intervertebral disc w/o myelopathy 721.0. Cervical Spondylosis w/o myelopathy 722.10. Displmt of lumbar intervertebral w/o myelopa 721.2 Thoracic Spondylosis w/o myelopathy 722.11 Displmt of thoracic intervertebral w/o myelopa 721.3 Lumbosacral spondylosis w/o myelopathy 722.4 Degeneration of cervical intervertebral disc 721.90. Spondylosis of unspec. site w/o myelopathy 722.51 Degeneration of thoracolumbar intervert. disc 723.1 Cervicalgia 722.52 Degeneration of lumbosacral intervert. disc 724.1 Pain in the thoracic spine 722.81 Postlaminectomy syndrome cervical region 724.2 Lumbago 722.82 Postlaminectomy syndrome thoracic region 724.5 Backache unspecified 722.83 Postlaminectomy syndrome lumbar region 728.85 Muscle Spasm 723.0. spinal Stenosis in cervical region 784.0. Headache 724.01 Spinal Stenosis, thoracic region 724.02 Spinal Stenosis, lumbar region MODERATE TERM CARE 724.3 Sciatica 353.0. Brachial Plexus Lesions 756.12 Spondylolisthesis 353.1 Lumbosacral Plexus Lesions 353.2 Cervical Root Lesions 353.3 Thoracic Root Lesions IN BOXES #1 & #3 YOU MUST USE THESE 353.4 Lumbosacral Root Lesions FOR MEDICARE CLAIMS 353.8 Other nerve Root and Plexus Disorders SUBLUXATION CODES 355.0. Lesion of the sciatic Nerve 739.0. HEAD 355.2 Other Lesions of fermoral nerve 739.1 CERVICAL 355.8 Mononeuritis of Lower Limb Unspecified 739.2 THORACIC 719.48 Pain in joint (other spec. sites)(must specify site) 739.3 LUMBAR 720.1 Spinal Enthesopathy 739.4 SACRAL 722.91 Other & Unspec. disc disorder, cervical reg. 739.5 PELVIC 722.92 Other & Unspec. disc disorder, thoracic reg 722.93 Other & unspec. disc disorder, Lumbar reg 723.2 Cervicocranial Syndrome 723.3 Cericobrachial Syndrome 723.4 Brachial Neuritis or radiculitis 723.5 Torticollis unspecified 724.4 Thoracic or lumbosacral neuritis or radiculitis 724.6 Disorder of sacrum, ankylosis 724.79 Coccygodynia (disorder of coccyx) 724.8 Other Symptoms referable to back, facet syndr 729.1 Myalgia and myositis unspec 729.4 Fascitis unspec 738.4 Acquired spondylolisthesis 756.11 Spondylosis, lumbosacral reg 846.0. Sprain/Strain of lumbosacral (joint)(ligament) 846.1 Sprain/Strain of sacroiliac ligament 846.2 Sprain/strain of Sacrospinatus (ligament)
This was quoted in the April 19th, 2005 WPS Seminar:
Budget Neutrality:
Legislation requires demonstration to be budget neutral
If demonstration is not found to be cost neutral (based on it’s estimated impact on Medicare Part A and Part B costs), CMS will RECOUP excess costs via payments made to all Medicare chiropractic service providers
Aggregate Medicare provider payments may not exceed amount that would have been paid in absence of demonstration.
CMS anticipates any necessary fee reduction to be made in the 2010 and 2011 fee schedules
Detailed analysis of budget neutrality and proposed offset will be published in the 2009 Federal Register publication of physician fee schedule. If CMS determines that the adjustment would exceed 2% of chiropractor fee schedule, it will implement the adjustment over a 2 year period
For more information on Medicare billing go to:
Tables: Fee Schedule Amounts, Zip Codes, Procedure Codes, and Diagnosis Codes
To access the tables referenced in this article, please see the article at:
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0514.pdf
Chiropractic Book Guide from Medicare:
http://www.wpsic.com/medicare/provider/pdfs/chiro_care_book.pdf
This is posted for informational purpose, this is quoted straight from the Medicare April Communique Archives listed at http://www.wpsic.com/medicare/provider/provhome.shtml
These rules apply when billing Medicare in Demonstration areas listed in the first paragraph. If you are NOT in the Demonstration Project, Medicare will only pay for the CMT (98940-42) for active care.
Return to the MEDICARE DEMONSTRATION PROJECT Page
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