De-Mystifying Active vs. Maintenance Care with Medicare, Part 2

Medicare Gives You the Rules: Just Follow Them

When a doctor does the work of diagnosing, treating, and documenting, there are both risks and rewards. All doctors want to be paid for the clinically reasonable and medically necessary services and procedures rendered to patients, so it is important to understand the contracts that might be required and each company’s definition of medical necessity. Often, a doctor’s definition of what is clinically appropriate doesn’t match that of the insurance carrier. A solid understanding of these details will make it easier for doctors to explain to patients which visits Medicare should be financially responsible for and which are the responsibility of the patient.

One of the best things about Medicare is that it sets the rules. Part 1 of this blog covered Medicare’s definition of Medical Necessity for active Chiropractic treatment, and the AT modifier attached to the CPT’s CMT codes 98940-98942.  It would be prudent to review that blog.

Medicare has a lot of moving parts with very specific and intentional language, definitions, and rules.  It is important to understand each of these parts and to make every effort to play by Medicare’s rules because treating Medicare patients offers high rewards, personal gratification, and solid grounding simultaneously.

Some of Medicare’s Playbook for Medically Necessary “AT”:

• Coverage for Chiropractic services is specifically limited to manual manipulation of the spine to correct subluxation (manipulative services are part of the Medical Necessity definition).
• There must be the presence of a subluxation that causes a significant neuromusculoskeletal (NMS) condition.
  • The examination must reveal a primary Subluxation that can be treated by CMT manual means, and it must be causing an NMS condition. These are the primary and secondary diagnoses.
  • The subluxation must be consistent with the complaint/condition that the patient stated as the reason for seeking care (Chief Complaint). The areas of complaint and Subluxation must be compatible with one another for each area treated.
  • Medicare suggests checking the appropriate Medicare Administrative Contractor (MAC) and the Local Coverage Determination (LCD) for specific requirements (e.g., the MAC Noridian notes the primary Subluxation’s documentation should reflect the SEVERITY of the condition).
• Documentation of the subluxation is needed. Proof of a subluxation can be demonstrated by one of two methods: x-ray or physical examination. If documented by physical examination, the P.A.R.T system must be used. Using the physical exam as an example:
  • P.A.R.T. criteria are required by Medicare to diagnose the primary Subluxation.
  • P.A.R.T. stands for P=Pain/Tenderness, A=Asymmetry/Misalignment, R=Range of Motion, T=Tone/Tissue Changes.
    • Of the four criteria (in PART), two of the four must be met AND one of the two MUST be the A or R component.
  • A primary subluxation must be present for each visit and each area or complaint treated.
  • Because PART was used, the physical examination requirements are similar for initial evaluations, reevaluations, and Subsequent or Routine Office Visits.
• The documentation for initial Evaluation and Management (E/M) visits (codes 99201-99205) and reevaluation visits (99212-99215) will be more extensive than the documentation for subsequent visits.
  • There have been important changes in how the level of care for the E&M codes is determined.
    • The KMC University Library and resources are excellent sources of information.
    • The key is Medical Decision Making or Time documentation.
    • This does not negate the need for an appropriate medical or Chiropractic history and examination.
      • The health of the patient comes first.
      • Without a thorough history intake or evaluation, a proper diagnosis or a more serious condition that is causing the Subluxation might go undetected.
    • As a result of the bullet point immediately above, CMS requires the following documentation:
      • Date of the initial treatment
      • Description of the current illness
      • Symptoms directly related to the level of Subluxation that caused the patient to seek treatment
    • CMS recommends documenting the following elements to prove medical necessity as they can lend credence to the severity of the problem:
      • Mechanism of trauma-what happened? Why did they call for this appointment? In the absence of a specific incident, document the ruling out of accident, fall, trip, or other trauma.
      • Quality and character of symptoms or problem-Use your descriptive language here
      • Aggravating and relieving factors
      • Others
    • Familiarity with the MAC and LCDs is extremely important. This ensures that the patient and Medicare get exactly what was requested along with various options for secondary diagnoses.
    • Medicare’s focus on a significant health problem that carries with it a loss of Function requires a plan that includes specific, measurable patient goals to be achieved as part of the process for verifying the patient’s status.
      • These goals are function-oriented
      • Approved OATs (Outcome Assessment Tools) are an excellent source of information
    • A recommended level of care (including specific treatment goals and objective measures to evaluate effectiveness) must be included.

Medicare publishes Local Coverage Articles (LCAs) which outline the rules and potential permitted diagnosis codes. Medicare patients can bounce between episodes of active and maintenance care, so it is imperative to recognize and document these episodes correctly. KMC University has all this information and more on hand. We’d love to help you make Medicare your favorite payer.