This policy requires two diagnoses for each subluxation, a primary diagnosis (nonallopathic, ICD-10-CM codes M99.00-M99.05) and a secondary diagnosis from Categories I, II or III, this diagnosis being the cause of the subluxation. Since, after January 1, 1997, the chiropractor may bill for manipulations of up to five separate regions (a subluxation in each region), this diagnostic requirement may lead to five different primary diagnoses and five different secondary diagnoses. The CMS-1500 claim form has space, in Item 21, for four diagnoses. Electronic submitters also have the option of submitting up to four diagnoses. Item 24E of the CMS-1500 claim form or the electronic equivalent will accept one of these four diagnoses, as the diagnosis that justifies the treatment/service reported. It follows then, that, since both paper and electronic claims cannot accept more than four diagnoses, and if three, four, or five re gions were treated leading to six, eight, or ten diagnoses, the question will be asked as to which four diagnoses to put on the claim form.
Full Answer
What is the CPT code for subluxation treatment?
Coverage is limited to manual manipulation of the spine to correct a subluxation. CPT Codes 98940, 98941, and 98942 accurately reflect such services. Documentation must clearly reflect the medical necessity for the service billed.
Does Medicare pay for treatment for subluxation?
• Medicare only pays for active/corrective treatment to correct acute or chronic subluxation. Medicare does not pay for maintenance therapy. - Active treatment: submit HCPCS modifier AT.
How many regions of subluxation can I Bill for?
If billing for three to five regions of subluxation, documentation must support both primary and secondary codes for each region individually.
What is the best practice for the diagnosis of subluxation?
Consider that the best practice is to correlate each symptom reported by the patient, to findings within your examination, leading to the diagnosis of the primary subluxation and secondary condition that will be addressed in the treatment plan.
Does Medicare cover DX code Z00 00?
Though the diagnosis code (ICD-10 code) for the exam is Z00. 00 (general physical exam), the CPT code for the visit is NOT the wellness-exam code range used by every other insurance plan (99381-99397). Instead, it is billed with a Medicare-only code, G0438.
What is a GY modifier used for?
GY Modifier: This modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded.
How many diagnoses can be reported on the CMS-1500?
twelve diagnosesUp to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim. However, only one diagnosis can be linked to each line item, whether billing on paper or electronically.
What form populates the diagnosis codes and procedures codes into the electronic claim form?
The superbill/encounter form –This preprinted form is filled out on each visit and contains the codes that are used in the particular healthcare setting. This form will have the diagnosis codes and procedure codes designated by the physician at the completion of the encounter.
What is the difference between modifier GY and GZ?
Definitions of the GA, GY, and GZ Modifiers The modifiers are defined below: GA - Waiver of liability statement on file. GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit. GZ - Item or service expected to be denied as not reasonable and necessary.
What is GT modifier?
What is GT Modifier? GT is the modifier that is most commonly used for telehealth claims. Per the AMA, the modifier means “via interactive audio and video telecommunications systems.” You can append GT to any CPT code for services that were provided via telemedicine.
What is the maximum number of diagnosis codes that you can put on the claim?
While you can include up to 12 diagnosis codes on a single claim form, only four of those diagnosis codes can map to a specific CPT code. That's because the current 1500 form allows space for up to four diagnosis pointers per line, and that won't change with the transition to ICD-10.
What is the maximum number of ICD-10 CM diagnosis codes that can be entered on a single CMS-1500 claim form?
The National Uniform Claim Committee NUCC is a voluntary organization composed of various members. A maximum of 10 ICD-9-CM or ICD-10-CM diagnosis codes can be entered on the CMS-1500 claim form.
Is a diagnosis pointer required for each DOS?
When a CPT code is billed, the provider must connect or “point” the diagnosis to each procedure performed to treat the specific diagnosis, so at least one pointer per CPT code is required and the total number of diagnosis pointers per CPT code are limited to four (4).
What is the difference between a UB and 1500?
The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities. This would include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS-1500) is used to submit charges covered under Medicare Part B.
What information is required on CMS 1500 form?
This is a required field and must be filled in completely. Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and Page 2 Instructions on how to fill out the CMS 1500 Form telephone number.
What goes in Box 14 of the CMS 1500 form?
Box 14 - Date of Current Illness, Injury, or Pregnancy (LMP) Enter the applicable qualifier to identify which date is being reported.
How many diagnoses are needed for a subluxation?
This policy requires two diagnoses for each subluxation, a primary diagnosis (nonallopathic, ICD-10-CM codes M99.00-M99.05) and a secondary diagnosis from Categories I, II or III, this diagnosis being the cause of the subluxation. Since, after January 1, 1997, the chiropractor may bill for manipulations of up to five separate regions (a subluxation in each region), this diagnostic requirement may lead to five different primary diagnoses and five different secondary diagnoses. The CMS-1500 claim form has space, in Item 21, for four diagnoses. Electronic submitters also have the option of submitting up to four diagnoses. Item 24E of the CMS-1500 claim form or the electronic equivalent will accept one of these four diagnoses, as the diagnosis that justifies the treatment/service reported. It follows then, that, since both paper and electronic claims cannot accept more than four diagnoses, and if three, four, or five re gions were treated leading to six, eight, or ten diagnoses, the question will be asked as to which four diagnoses to put on the claim form.
What is the diagnosis of subluxation?
Subluxation is defined as the incomplete dislocation, off centering, misalignment, fixation or abnormal spacing of vertebrae or intervertebral units. Subluxations are classified as either:
What does subluxation mean in Medicare?
For the purposes of Medicare, subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebra anatomically. ". A recent U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) report about chiropractors says:
What is the diagnosis of subluxation in chiropractic?
It is the so-called vertebral “subluxation.” It is the diagnosis that justifies the performance of a chiropractic manipulative treatment, or an adjustment, which is by far the most commonly performed procedure in a chiropractic setting.
What is the ICd 10 code for lumbar subluxation?
The injury section of Chapter 19 of ICD-10-CM offers codes that also appear to use the proper term as described by doctors of chiropractic: S13.1 for cervical subluxations, S23.1 for thoracic subluxations, and S33.1 for lumbar subluxations (with the sixth character “0”). However, there are several reasons why these may not be the best option: 1 They are the matches for the old 839 category, which was not payable by Medicare. 2 This entire chapter is for acute injuries, and the “includes” list for each of these categories include sprains and other serious traumatic issues. Many chiropractic patients have a chiropractic “subluxation” without trauma. 3 To use these codes, the provider also must document a specific interspace to explain which bone is dislocated. However, the chiropractic subluxation usually describes a segment (not the space between two segments) that is misaligned or fixated. 4 There are no subluxation codes offered in these ranges for L5/S1 or the sacroiliac joints. But these are joints that are typically treated by chiropractors. 5 These codes also require a seventh character to designate the episode of care, which is a bit confusing if you try to force it into the chiropractic model.
What is partial dislocation?
In a typical medical dictionary it is simply a “partial dislocation,” which implies some sort of torn ligaments and/or trauma. However, a different definition, such as the following from Medicare, should be considered for the chiropractic provider:
Is subluxation a Medicare approved code?
These codes appear to use the verbiage many chiropractors are looking for, but unfortunately, they are not listed on any Medicare-approved lists. This may be because the word “subluxation” in these codes still means “partial dislocation” to coders and payers.
Do dislocations need to be immobilized?
And dislocations typically need to be immobilized rather than manipulated. It may be wise to check with specific payers before using these codes to justify manipulation. This brings us back to M99.0 codes, which Medicare has recommended. However, the documentation should match the diagnosis code selected for a claim.
Is subluxation still missing?
The word “subluxation” is still missing. However, these are the codes that most Medicare contractors have instructed chiropractors to use, and private payers appear to have followed suit. The next group of codes in the tabular List are in the M99.1 subcategory, which is defined as “subluxation complex (vertebral).”.
What is Medicare subluxation?
For most chiropractors, Medicare diagnosis consists of both a primary (subluxation) and a secondary diagnosis for each region of the spine they intend to treat. The secondary diagnosis describes the secondary, neuromusculoskeletal condition relating to each primary subluxation.
Is chiropractic diagnosis code required for Medicare?
Accurately describing your patient’s condition using chiropractic diagnosis codes for Medicare is part of your documentation requirement. Using overly-simple, non-descriptive diagnoses attempt to lay the foundation for necessary care is a lose-lose situation. Both the patient and the provider lose because Medicare doesn’t get an accurate picture of their need for care. Resolve to pump up your documentation with better history, stronger examination findings, and accurately reported chiropractic diagnosis codes for Medicare in 2019. Then everybody wins!
Is chiropractic a Medicare diagnosis?
Chiropractic Diagnosis Codes for Medicare in 2019: Choose Wisely! Many Chiropractors think that diagnosing Medicare patients is one of the simpler things they must do. After all, most Part B Medicare Administrative Contractors (MAC) provide a list of approved diagnosis codes to use. Many even provide guidance on the frequency limitations ...
What is subluxation diagnosis?
Diagnosis: Primary diagnosis must be subluxation, including level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to condition of spinal joint involved or to direction of position assumed by particular bone named.
What is the CPT code for spinal manipulation?
Coverage is limited to manual manipulation of the spine to correct a subluxation. CPT Codes 98940, 98941, and 98942 accurately reflect such services. Documentation must clearly reflect the medical necessity for the service billed.
Is spinal segment manipulated on day of visit documented in patient's record?
Exact spinal segment manipulated on day of visit must be documented in patient's record. Simply stating region is not sufficient. Documentation generated after visit date for purposes of supplying information to Medicare when requested is considered a supplemental report and is not considered actual daily chart notes.
Does Medicare require chiropractors to use AT modifier?
For Medicare purposes, a chiropractor MUST append an AT modifier on a claim when providing active/corrective therapy to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary.