Proper Procedure and Diagnosis Coding for Maintenance Services
“Not Medically Necessary” is among the most common third-party denials in chiropractic. What results is a slew of record requests, audits, refund requests, and denials for care. In many instances, a practice may opt to stand behind those services and take steps to appeal the claim(s) for payment, asserting that care was indeed medically necessary. Unfortunately, we often find that care was indeed for maintenance services and therefore, not reimbursable by most third-party carriers. So then, what to do when your provider agreements require that you submit the billing, even if you are not requesting reimbursement? As a measure of risk management, as well as compliance in coding guidelines, when maintenance care is performed, the appropriate codes must be utilized, both in your practice management software and in your billing to the carrier.
How to Code for Maintenance Treatment
There are many vulnerabilities to a practice for the use of inaccurate codes. Coding for maintenance care is a common coding error in our industry.
The most fundamental rule of both service/procedure and diagnosis coding requires that the code selected to report a service must be the code which most closely defines the service rendered. Coding for maintenance care is no exception.
Maintenance care services for non-Medicare patients is correctly coded using the HCPCS code S8990. This is the definition:
S8990 – Physical or manipulative therapy performed for maintenance rather than restoration.
S8990 is a very broad maintenance care code which includes not only chiropractic adjustments but also all services performed for maintenance rather than restoration.
Important Maintenance Procedure Coding Rules
A couple of extremely important maintenance care rules include appropriate use for Medicare and other private payers. See below for that breakdown:
- Private Payers: While maintenance care is rarely covered, if you must submit the bill for maintenance therapy to a private payer, code S8990 is usually the most appropriate code to use. Each payer is different, so be sure to check carrier contracts or contact the private payer directly to verify that the S8990 is preferred and acceptable. Some have even deemed this code “investigational” and have forbidden charges to the patient. Always check the rules before billing.
- Medicare: S8990 is not permitted for Medicare maintenance care under any circumstances. Practices must follow standard Medicare guidelines and report maintenance care using only the appropriate CMT code (9894-), followed by the GA modifier, to indicate that the required Advance Beneficiary Notice (ABN) has been signed and is on file for this maintenance care procedure. Remember, only submit to Medicare if the patient has selected Option 1 on the ABN. Option 2 does not require billing to the Medicare carrier.
What About Diagnosis Codes?
Further, along with proper procedure coding (CPT/HCPCS), diagnosing (ICD-10) to adequately represent maintenance care services does not follow what you would typically use for third-party submission and reimbursement. Bear in mind that maintenance care does not require support of medical necessity and in fact, is exactly the opposite. As such, a generalized maintenance related diagnosis is most appropriate for use. Although only one supporting diagnosis is necessary, here are a few options to consider in order to select that which is most appropriate for each patient scenario:
|Z00.00||Encounter for general adult medical examination without abnormal findings; Encounter for adult health check-up NOS (Not Otherwise Specified)|
|Z00.01||Encounter for general adult medical examination with abnormal findings|
|Z13.82||Encounter or screening for musculoskeletal disorder|
|Z41.8||Encounter for other procedures for purposes other than remedying health state|
Importantly, when using Z00.00, be aware that this is intended to be used when the patient presents for care and has no complaint. Notice that code Z00.01 includes the description of “with abnormal findings.” Abnormal findings, in this case, refers to new abnormal findings according to the exam rendered and is not applicable for previously diagnosed chronic conditions. Finally, many practices find that Z41.8 is most often the best code selection for routine maintenance treatment.
Manage Coding for Statistical Purposes
Identifying CMT services properly in your software is the first step in ensuring proper coding, data entry, and billing. It aids in the prevention of data entry-related errors and is the best way to ensure that the appropriate service code has been selected for your CMT service. The four CMT categories recommended for proper software set up are shown in the table below.
|9894x||The appropriate CMT service (98940-98942) should be a designated selection for software data entry. Entering this service appropriately identifies Active Care, Non-Medicare. The appropriate Active Care diagnosis is assigned with this code in order to support medical necessity and expectation of third party coverage.|
|9894x – AT||The appropriate CMT service (98940-98942) appended with an AT modifier is used in data entry to report Active Care, Medicare. The appropriate supporting diagnosis is included to further validate an Active CMT procedure. To Medicare, this code indicates that care is medically necessary and Medicare coverage is expected.|
|9894x – GA||The appropriate CMT service (98940-98942) appended with a GA modifier is used in data entry to report procedures that are non-medically necessary, Maintenance Care, or Medicare. The appropriate Maintenance Care diagnosis is included to further define a maintenance care CMT procedure. To Medicare, this code indicates that care is not medically necessary; that the practice collected a signed Waiver of Liability (ABN) from the patient; and Medicare coverage and payment is not expected.|
|S8990||S8990 is the appropriate code when reporting Maintenance Care, non-Medicare. This may be appropriate for standard third-party payors and non-insurance patients who are receiving maintenance care, CMT services, or other maintenance-type therapies.|