The Centers for Medicare & Medicaid Services (CMS) has further defined Chiropractic Maintenance Therapy. Section 2251.3 of the Medicare Carriers Manual (MCM) has been amended to clarify Medicare requirements for treatment of chiropractic therapy.

"MCM 2251.3 Necessity for Treatment.--

A. 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. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam, as described above.

Most spinal joint problems may be categorized as follows:

• Acute subluxation: A patient?s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, arrest or retardation of the patient?s condition.

• Chronic subluxation: A patient?s condition is considered chronic when it is not expected to completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, without expectation of additional functional improvement, further manipulative treatment is considered maintenance therapy and is not covered.

B. Maintenance Therapy.-Chiropractic maintenance therapy is not medically reasonable or necessary and is not payable under the Medicare program. Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition."

Maintenance therapy is not a Medicare benefit. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered a covered service under the Medicare program. Coverage will be denied if documentation does not clearly demonstrate that there is reasonable expectation that the continuation of treatment would result in significant long-term improvement of the patient?s condition. Continued repetitive treatment without an achievable and clearly defined clinical end point isconsidered maintenance therapy and is not covered.

Neither Noridian Administrative Services (NAS) nor Medicare has taken the position that maintenance care is of no benefit for the patient. It is simply not covered.

Billing Maintenance Therapy

Maintenance therapy should be billed with diagnosis code V57.9, unspecified rehabilitation procedure. An Advance Beneficiary Notice (ABN) should be obtained which states that the treatment is maintenance and the procedure code should be billed with modifier GA. Maintenance therapy will be denied as not medically necessary.

When Congress passed the Omnibus Budget Reconciliation Act of 1989, it included the requirement that providers and suppliers submit Medicare claims for all covered services on behalf of Medicare beneficiaries, beginning September 1, 1990.

Chiropractic services are considered to be a covered service. When the service becomes maintenance, it is considered ?not medically reasonable or necessary.? What this means to the chiropractic community is that these services, although they are not reimbursable under Medicare standards, must be billed to Medicare even though they will be denied.

If, on review by NAS, the provider is found to bill maintenance chiropractic therapy without using diagnosis code V57.9, and, if on further review NAS finds that the provider continues this inappropriate billing, NAS will consider this an abuse of the Medicare fund.

For additional information and coverage criteria, please consult the entire Chiropractic Policy, published in "Medicare B News," Issue 199, dated October 15, 2002.

Applies to the states of: AK, AZ, CO, HI, IA, NV, ND, OR, SD, WA & WY.

Effective Immediately

Source: Program Transmittal 1805, Change Request 2717, dated June 27, 2003