Coding Maintenance Care: Medicare and Other Third-Party Payers

Can We Bill Maintenance Care Services to Third-Party Payers?

In the quest to run a compliant practice, providers manage their patients in episodes of care. During active care, the patient’s condition meets the definition of medically necessary care, while maintenance care supports and maintains the restored level of function and health achieved during the active episode. As the patient transitions to maintenance care, a common question is, “Can we bill maintenance care services to third-party payers?” The answer may vary depending on the payer, but the rule of thumb is not to bill maintenance care to any third-party payer unless you have documented proof that it is a covered service for that payer.

Active VS Maintenance

Many of the policies of the Affordable Health Care Act include habilitative coverage. Providers need to confirm if this is inclusive of chiropractic services. Some policies clearly state it does not pertain to chiropractic, while others are broader in their acceptance. Additionally, some union or self-funded plans may cover a specific number of visits in a calendar year, regardless of medical necessity.

If you deal with a third-party payer who will consider reimbursement for maintenance charges, be careful to utilize appropriate diagnosis codes for maintenance care specifically rather than active condition codes.

Most third-party payers have distinct definitions of what they consider active versus maintenance care. As a Doctor of Chiropractic, you need to be familiar with these definitions for each payer you submit claims to.

Billing and Coding Responsibly

There are providers who attempt to find ways around these defined terms by utilizing different codes to describe the care and then bill the payer for it. This is not acceptable. Take a moment to read the following statement issued by the American Chiropractic Association (ACA) on this topic:

“ACA often fields questions from doctors asking whether HCPCS code S8990 (“Physical or manipulative therapy performed for maintenance rather than restoration”) should be reported to Medicare for maintenance manipulation. This code should not be reported. S-codes, including S8990, were developed for use in the private sector only – they were never intended for use with Medicare. Using non-standard Medicare coding could raise a red flag with your contractor. When reporting maintenance chiropractic manipulative treatment to a CMS contractor (Medicare), use codes 98940-98943 without an AT modifier.”

While it may, at times, be appropriate to utilize S8990 with a private payer, or when creating your fee schedule, it is of utmost importance that you first clearly understand what maintenance care entails, and never bill this to a third-party payer unless, as stated previously, you have documented proof from the payer that it is a covered service.

Additionally, it is necessary to create an office policy regarding this and utilize the appropriate procedure and diagnosis codes to state this is for maintenance. Maintenance care is a vital component of what sets Chiropractic apart in the healthcare profession. Let’s make sure we are coding and billing it right!

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.