There are many definitions and rules around establishing medical necessity. Because there is rarely a standard of documentation more stringent than Medicare, KMC University recommends using Medicare definitions and guidelines to create your standard for documentation. Sometimes, third-party payers will publish their own requirements for medical record keeping, in which case, this more specific standard should be followed. In the absence of such clarity, use the Medicare standard. Always delineate the care that should be covered by third-party payers from care that is ‘clinically appropriate’ but not ‘medically necessary’ and is therefore the patient’s financial responsibility. Definitions found in the payers’ review policy can help. Medicare publishes these definitions in the LCDs located on the contractor’s website. In 2018, we’re expecting many changes to the LCD, clarifying medically necessary care and documentation requirements. KMC University will stay on the lookout and provide notice when we see that they have been updated.
The following current definitions come directly from 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 while providing a reasonable expectation of recovery or improvement of function.
When the patient is being treated for a new injury identified by X-ray or physical exam as specified above. The chiropractic manipulation is expected to result in an improvement in, or arrest the progression of, the patient's condition.
When the patient’s condition is not expected to significantly improve or be resolved with further treatment, but the continued therapy is expected to result in some functional improvement. Once the clinical status is stable for a given condition, and no additional objective clinical improvements are expected, further manipulative treatment is considered maintenance therapy and is not covered.
A treatment plan that seeks to prevent disease, promotes health, and prolongs and enhances the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement is not expected from continuous, ongoing care, and the chiropractic treatment is supportive rather than corrective in nature, the treatment is considered maintenance therapy. Chiropractic maintenance therapy is not considered medically reasonable or necessary under the Medicare program and is not payable.
A temporary but marked deterioration of a patient’s condition that is causing significant interference with activities of daily living due to an acute flare-up of a previously treated condition. The patient’s clinical record must specify the date of occurrence, nature of the onset, or other pertinent factors that support the medical necessity for treatment. As with an acute injury, treatment should result in an improvement of or an arrest of the deterioration in a reasonable period of time.
Represents an acute change that is a marked deterioration of the patient’s condition and that is causing significant interference with activities of daily living. ‘Active treatment’ can only occur as long as the patient is achieving significant clinical improvement.
Medicare has specific requirements for documentation to prove medical necessity. These standards are published in most chiropractic Local Coverage Determination (LCD) documents. Medicare LCDs are important documents to obtain and review each new year! Many updates are taking place in 2018 that your practice must be prepared for in order to document, code and bill properly. KMC University Library members have access to regional LCD documents, located in your Medicare Department on your personal, client dashboard.