FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION
CODING GUIDELINES
LCD Number
98940
Contractor
Name
First Coast Service
Options, Inc.
Contractor
Number
09102 – Florida
09202 – Puerto Rico
09302 – Virgin Islands
LCD Title
Chiropractic
Services
Coding
Guidelines
The date of initial
treatment or date of exacerbation or reinjury of the existing condition must be
entered in Item 14 of FORM CMS 1500.
This serves as affirmation by the chiropractor that all documentation
requirements are being maintained on file by the chiropractor.
If an x-ray is used
to determine the level of subluxation, put the date of the x-ray in Item 19 on
the CMS 1500 form.
Procedure codes 98940- 98942 do not represent add-on
codes wherein more than one is required to report additional regions. For example, to report CMT of five spinal
regions you report only code 98942
as this code includes all five regions.
Effective for services
rendered on or after 10/01/2004:
·
When
providing active/corrective treatment for acute or chronic subluxation, an AT
(Acute Treatment) modifier must be placed on the claim when billing
procedure codes 98940, 98941, or 98942.
Claims for medically necessary services must contain the AT modifier to
reflect such services provided or the claim will be denied. However, the presence of the AT modifier may
not in all instances indicate that the service is reasonable and
necessary. As always, contractors may
deny if appropriate after medical review.
·
When
providing maintenance therapy, no modifier is required when billing procedure
codes 98940, 98941, or 98942. The AT
modifier must not be placed on the claim when maintenance therapy has
been provided. Claims without the AT
modifier will be considered as maintenance therapy and denied.
Reasons for
Denials
When performed for
indications other than those listed in the "Indications and Limitations of
Coverage and/or Medical Necessity" section of this policy.
Services would not
be considered medically reasonable and necessary in the absence of pain or
symptomatology resulting from a subluxation of the spine.
Medicare’s coverage
for Chiropractic services is limited to manual manipulation of the spine. Any other diagnostic or therapeutic
services(s) furnished by a chiropractor or under his or her order will be
denied.
All claims submitted
for chiropractic manipulative treatment by specialties other than specialty 35
(Chiropractor) will be denied.
Procedure code 98943 is a non-covered service.
Other
Comments
Chiropractic or
physician consultation should be utilized for the review process, if there is a
question as to the validity of medical necessity of the claim.
The following terms
are used in this policy:
Ankylosis: immobility and consolidation of a joint due
to disease, injury or surgical procedure.
Arthritis: rheumatism in which the inflammatory lesions
are confined to the joints.
Arthrosis: a joint or articulation; a disease of a
joint.
Atlanto: occipital - region of the spine pertaining
to the occiput and the first cervical segment.
Axis: second cervical segment of the spine.
Chronic: persisting over a long period of time:
designating a disease showing little change or of slow progression; opposite of
acute.
"C"
curve: the normal cervical lordosis.
Dorsal: refers to mid-back/thoracic region.
Flexion: bending.
Intervertebral
disc: layers of fibrocartilage between
the bodies of adjacent vertebrae, consisting of a fibrous ring enclosing a
pulpy center.
Kyphosis: "hunchback"; abnormal increase in
convexity in the curvature of the thoracic spine.
Lordosis: "sway back"; anterior concavity in
the curvature of the lumbar and cervical spine as viewed from the side.
Manipulation: (adjustment) - skillful treatment or
procedure involving the use of hands.
Paralysis: loss of motor function.
Paresis: weakness or incomplete paralysis.
Radicular
pain: pain resulting from nerve root
irritation.
Rotation: the process of turning around an axis.
Scoliosis: an appreciable lateral deviation in the
normally straight vertical line of the spine.
Spondylitis: inflammation of the vertebrae.
Subluxation: an incomplete dislocation, off-centering,
misalignment fixation or abnormal spacing of the vertebrae anatomically.
Vertebrae: any of the 33 bones of the spinal column,
comprising the 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 4 coccygeal
vertebrae.
Revision
History
|
Date |
Revision |
|
02/02/2009 –
Florida |
Original |
Document formatted:
11/11/2004 (JG/st)