Page 243 - Medicare Benefit Policy Manual

A. Maintenance Therapy

Maintenance therapy includes services that seek to prevent disease, promote health and
prolong and enhance the quality of life, or 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. The AT
modifier must not be placed on the claim when maintenance therapy has been provided.
Claims without the AT modifier will be considered as maintenance therapy and denied.
Chiropractors who give or receive from beneficiaries an ABN shall follow the
instructions in Pub. 100-04, Medicare Claims Processing Manual, chapter 23, section
20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.

B. Contraindications

Dynamic thrust is the therapeutic force or maneuver delivered by the physician during
manipulation in the anatomic region of involvement. A relative contraindication is a
condition that adds significant risk of injury to the patient from dynamic thrust, but does
not rule out the use of dynamic thrust. The doctor should discuss this risk with the
patient and record this in the chart. The following are relative contraindications to
dynamic thrust:

Articular hyper mobility and circumstances where the stability of the joint is
uncertain;

Severe demineralization of bone;

Benign bone tumors (spine);

Bleeding disorders and anticoagulant therapy; and

Radiculopathy with progressive neurological signs.

Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation
and proposed manipulation in the following:

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;