Claim Submission Requirements - JE Part B

Claim Submission for Covered Services

Caims submitted for treatment of subluxation must contain modifier AT to reflect services rendered providing active/corrective treatment to treat acute or chronic subluxation and clinical documentation must be available upon request to support use of all modifiers.

Note: The AT modifier does not (in all instances) indicate that service(s) is reasonable and necessary. After medical review, if appropriate, contractors may deny claim.

Although the claim form must be completed in its entirety, see Items 14, 17, 17b, 19, 21, 24D, 24E as each contain special notes to Chiropractors. See the Claim Form Instructions webpage for completion details.

Claim Submission for Noncovered Services

Claims received for active/corrective therapy (CPT codes 98940, 98941 or 98942) that are not submitted with modifier AT are considered maintenance therapy and are denied because maintenance chiropractic therapy.

When further clinical improvement cannot be expected from continuous ongoing care treatment is considered maintenance therapy (non-covered) (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). Do not append the AT modifier to these services. Providers may obtain an Advance Beneficiary Notice of Noncoverage (ABN) from the patient and append the modifier GA. Modifier GA indicates that the provider expects that Medicare will deny a service as not reasonable and necessary and that an ABN has been signed by the patient. If the provider expects that Medicare will deny an item or service as not reasonable and necessary and the patient has not signed an ABN, append modifier GZ.

If a chiropractor orders, takes or interprets an X-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the X-ray can be used for documentation. However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor.

In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are hand-held with the thrust of the force of the device being controlled manually. While such manual manipulation may be covered, there is no separate payment permitted for use of this device.

Services such as office visits (evaluation and management services), diagnostic studies, physical therapy and other services rendered by chiropractic are not required to be submitted for coverage consideration by the Medicare program. CMS does not require providers to submit claims for services that are excluded by statute under Section 1862(a)(1)(A) of the Social Security Act. If a Medicare beneficiary believes a service may be covered or requests a formal Medicare determination for consideration by a supplemental plan, the provider must submit a claim.

• To submit a claim for a non-covered service by a chiropractor, append modifier GY to indicate that the service is statutorily excluded from coverage
• Covered and non-covered services may be billed on the same claim

Note: Therapy services provided by a chiropractor, although non-covered, must be submitted according to therapy guidelines. Therefore, be sure to include one of the therapy modifiers on a claim. Therapy services submitted without the appropriate modifier will be rejected as unprocessable.