Page 242 - Medicare Benefit Policy Manual

Review of chief complaint;

Changes since last visit;

System review if relevant.

2. Physical exam

Exam of area of spine involved in diagnosis;

Assessment of change in patient condition since last visit;

Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

240.1.3 - Necessity for Treatment
(Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04)

The patient must have a significant health problem in the form of a neuromusculoskeletal
condition necessitating treatment, and the manipulative services rendered must have a
direct therapeutic relationship to the patient’s condition and provide reasonable
expectation of recovery or improvement of function. The patient must have a subluxation
of the spine as demonstrated by x-ray or physical exam, as described above.

Most spinal joint problems fall into the following categories:

• Acute subluxation-A patient’s condition is considered acute when the patient is
being treated for a new injury, identified by x-ray or physical exam as specified
above. The result of chiropractic manipulation is expected to be an improvement
in, or arrest of progression, of the patient’s condition.

• Chronic subluxation-A patient’s condition is considered chronic when it is not
expected to significantly improve or be resolved with further treatment (as is the
case with an acute condition), but where the continued therapy can be expected to
result in some functional improvement. Once the clinical status has remained
stable for a given condition, without expectation of additional objective clinical
improvements, further manipulative treatment is considered maintenance therapy
and is not covered.

For Medicare purposes, a chiropractor must place an AT modifier on a claim when
providing active/corrective treatment to treat acute or chronic subluxation. However the
presence of the AT modifier may not in all instances indicate that the service is
reasonable and necessary. As always, contractors may deny if appropriate after medical
review.