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Points to remember for Chiropractic services CPT code 98940, 98941, 98942

While billing the chiropractice services do remember the below points.

Report the initial treatment phase.
Report the date of X-ray if an X-ray is used to demonstrate subluxation. The X-ray film must be available for review upon request.
A physical examination may be used to document subluxation if an X-ray is not used. The physical examination must be documented in the medical record and must support the subluxation.
Report the level of subluxation using the appropriate ICD-10-CM code.
In addition to reporting the ICD-10-CM code for the level of subluxation, report any other pertinent ICD-10-CM codes.
All treatments must be categorized as either acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either “acute” or “chronic” (e.g., an identifiable re-injury would fall under acute).

Description of CPT code 98940, 98941, 98942

98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions

98941 spinal, 3-4 regions

98942 spinal, 5 regions

98943 extraspinal, 1 or more regions

The chiropractor uses these codes to report the unique manual treatments used to influence joint and neurophysiological function. Several modalities exist. Use CPT code 98940 if treatment is spinal, one to two regions; 98941 if treatment is spinal, three to four regions; 98942 if treatment is spinal, five regions; and CPT code 98943 if treatment is extraspinal (head, extremities, rib cage, and abdomen), one or more regions

Chiropractic manipulative treatment (CMT) procedures include the review of prior radiologic imaging, test interpretation, and test results and pre-manipulation patient assessment, and are considered inclusive components of the CMT codes (98940-98943). Additional E/M services are performed and reported separately with modifier 25, if and only if the patient’s condition requires a significant separately identifiable E/M service above and beyond the usual preservice work associated with the CMT procedure.

Modifiers used along with Chiropractic Services

The following modifiers should be reported with procedure code 98940, 98941, or 98942 as is appropriate to each patient’s situation:

AT – acute treatment
GA – authorization has been provided to notify the beneficiary of the likelihood that services will be denied as not reasonable and necessary under Medicare guidelines.
GZ – item or service expected to be denied as not reasonable and necessary

For Medicare purposes, the AT modifier shall now be used only when chiropractors bill for active/corrective treatment.

Every chiropractic claim (those containing HCPCS/CPT code 98940, 98941, 98942) with a date of service on or after October 1, 2004, to include the Acute Treatment (AT) modifier if active/corrective treatment is being performed; or
No modifier if maintenance therapy is being performed. Contractors shall deny a chiropractic claim (containing HCPCS/CPT code 98940, 98941, 98942) with a date of service on or after October 1, 2004, that does not contain the AT modifier.

CMT procedures include the review of prior radiologic imaging, test interpretation, and test results and pre-manipulation patient assessment, and are considered inclusive components of the CMT codes (98940-98943). Additional E/M services are performed and reported separately with modifier 25, if and only if the patient’s condition requires a significant separately identifiable E/M service above and beyond the usual preservice work associated with the CMT procedure.

The complete CMT service requires preservice and intraservice work that is included as part of the service

Preservice – The physician reviews the patient’s records and established treatment plan to familiarize himself or herself with the previous treatment. The physician then conceptualizes the range of potential manipulative treatments that may be performed in both body regions for the current date of service. The potential procedures are explained to the patient, verbal consent is obtained, and the physician answers any further questions, comments, and concerns.

Intra-service : A premanipulation patient assessment is performed, including assessment of the patient’s pain level using a numerical rating scale, evaluation of interval changes in objective signs, and evaluation of functional changes that may include identifying asymmetry, assessing segmental mobility, and evaluating changes in tissue and tone in both affected regions. The treatment procedure that best fits the patient’s condition that day is finalized. The patient is then placed in the prone position on the treatment table. Static and dynamic palpation is performed, which identifies primary involvement at T3-T4. The physician applies brief soft tissue manual therapy adjacent to spinal skeletal structures. The appropriate segmental level is identified in the adjusting position (T3-T4).

The physician makes a pisiform contact on the left transverse process of T3. Breathing instructions are given to the patient. The physician prestresses the periarticular soft tissues to identify the appropriate direction/amplitude of thrust. An articular (osseous) adjustive procedure is applied to the determined spinal lesion at T3-T4 utilizing a short-lever, high-velocity, low-amplitude (HVLA). Postadjustment procedures and interactive reassessments are made. The patient is then assisted in moving to a supine position. Chiropractic manipulative treatment is directed at C5-C6. Postadjustment procedures and interactive reassessments are made.

Reasons for Denial for Chiropractice Services

Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine. The chiropractor is not required to bill excluded services. However, if the beneficiary requests Medicare be billed, the provider must bill services to Medicare in order to obtain a denial for secondary insurance purposes. The following are examples (not an all-inclusive list) of services excluded from Medicare coverage when performed by a chiropractor; the beneficiary is responsible for payment.

Laboratory tests
X-rays
Office visits (history and physicals)
Physiotherapy
Traction
Supplies
Injections
Drugs
EKGs or any diagnostic study
Acupuncture
Orthopedic devices
Nutritional supplements/counseling
Any service ordered by the chiropractor

In addition, services will be denied, prospectively as well as retrospectively, when:

the contractor determines that the service is not medically reasonable and necessary; and/or
the medical record does not verify that the service described by the HCPCS code was provided; and/or
there exists one of the absolute contraindications; and/or
the mechanical or electric equipment, that is used for manipulation does not meet the definition of “manual device”
an X-ray or physical exam does not support one of the primary diagnoses listed in the “ICD-10 Codes That Support Medical Necessity”
the service was performed as maintenance therapy; and/or
the documentation, in the medical record is lacking the information required under the “Documentation Requirements”.

Common Reasons for Claim Rejection

The claim does not include a subluxation diagnosis code

Solution: The provider has not met the diagnosis requirements per the local coverage determination (LCD) for subluxation

Missing AT modifier

Solution: If the AT modifier is appropriate for the service, use the claims correction feature via the IVR or Novitasphere to correct the claim to add the modifier

Diagnosis code reported on claim is not listed as a covered Diagnosis per the LCD

Solution:Services are not covered for the diagnosis code billed

References:

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52987