New Medicare Guidelines Announced - Texas Journal of Chiropractic

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New Medicare Guidelines Announced

Published 10/19/2009 - 6:15 a.m. CDT

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In an announcement found here, TrailBlazer announced that:

Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.

Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per month and 30 chiropractic manipulation services per beneficiary per year. Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.

Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

Twelve (12) chiropractic manipulation treatments for Group A diagnoses.
Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.
Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.
Thirty (30) chiropractic manipulation treatments for Group D diagnoses.

"The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary."

"Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:"

"Medicare covers the following numbers of chiropractic manipulation services per beneficiary:

Twelve (12) chiropractic manipulation treatments per month.
Thirty (30) chiropractic manipulation treatments per year."

The entire LCD, including associated diagnosis code lists, documentation requirements, utilization guidelines and the related article, can be viewed at:

http://www.trailblazerhealth.com/Tools/LCDs.aspx?DomainID=1

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