Medical necessity to provide chiropractic services should be subluxation. Subluxation is defined as the incomplete dislocation, off centering, misalignment, fixation or abnormal spacing of vertebrae or intervertebral units. Subluxation are classified as either

  • Acute – such as strains and sprains 
  • Chronic – such as loss of joint mobility 
  • Nerve root problems – such as pinched nerve.
Use of X-rays in Chiropractic services:

  • Effective for claims with dates of services on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation. However, an x-ray may be used for this purpose if the chiropractor chooses so.
  • The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. 
  • Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment.
  • In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. 
  • A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.
  • The x-ray must be made available to Medicare when requested. If the spinal x-ray(s) have been taken in a hospital or outpatient facility, a written report, including interpretation and diagnosis must be present in the patient’s clinical record. 
  • The x-ray film(s) must be labeled with the patient’s name and date the x-ray was taken, and must be marked right or left. The date of the x-ray must be entered in Item 19 the CMS1500 claim form or in the narrative field for electronic claims. 
  • For an x-ray to be used, it must have been ordered, taken and interpreted by a physician who is an MD or DO 

Physical Exam:

  • In lieu of an x-ray, a subluxation may be demonstrated by physical examination meeting the requirements listed below:
  1. a. Pain/tenderness evaluated in terms of location, quality and intensity; 
  2. b. Asymmetry/misalignment Identified on a sectional or segmental level; 
  3. c. Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and 
  4. d. Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle and ligament.

Documentation Requirements:

Additionally, the below discussed documentation requirement, must be met.

  • The documentation of an exacerbation must be entered into the narrative field of an EMC claim or as an attachment with a CMS-1500 claim form.

Places of Service:

  • Manual spinal manipulations may be performed in the home, office, nursing home, skilled nursing facility, inpatient facility or outpatient setting.

Diagnoses Covered: 

This policy requires two diagnoses for each subluxation, a primary diagnosis (non-allopathic, ICD-10-CM codes M99.00-M99.05) and a secondary diagnosis from Categories I, II or III, this diagnosis being the cause of the subluxation. 

Use of AT Modifier:

  • When you provide acute or chronic active/corrective treatment to Medicare patients, you must add the AT (acute treatment) modifier to every claim that uses HCPCS 98940, 98941, or 98942. 
  • If you do not use this modifier, your care will be considered as maintenance therapy and will be denied because maintenance chiropractic therapy is not considered medically reasonable and necessary under Medicare.
  • For services that are maintenance therapy, you may wish to obtain an Advance Beneficiary Notice (ABN) from the beneficiary and also apply the GA modifier (to be used when you want to indicate that you expect that Medicare will deny a service as not reasonable and necessary and that you do have on file an ABN signed by the beneficiary) or the GZ modifier (to be used when you want to indicate that you expect that Medicare will deny an item or service as not reasonable and necessary and that you have not had an ABN signed by the beneficiary) as appropriate.