Important Medicare Definitions
Acute Treatment
CMS considers the Medicare definition of treatment acute when “a patient is being treated for a new injury, identified by x-ray or physical exam. . . . The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.”
Chronic Treatment
CMS considers treatment chronic when the patient’s condition is “not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.”
Maintenance Therapy
CMS considers treatment maintenance therapy when the therapy in question “is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.”
Medical Necessity for Chiropractic Adjustment According to Medicare
“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of FUNCTION.”
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I am writing in regards to the KMC Compliance program my office signed up for. At first, I thought it would just be a program to look at our office and make sure we were doing things correctly, but as the meetings went on I realized the KMC program provided a ton of information at my fingertips. I have worked in chiropractic offices for 12 years (and currently work in two), and this is the first time I finally felt like I was receiving the answers to 'grey area' questions I've had for quite some time. I absolutely love the training videos, and the one on one meetings with you were greatly appreciated. We got knowledgeable and personalized answers based on our practices needs. I highly recommend this program to any practice considering it, having doctors and staff trained in this is an absolute necessity if that practice is accepting insurances. Thank you for all your help with making sure our office is compliant and has the knowledge to continue dealing with all the rules and regulations of very confusing insurance policies.