what is the medicare coding requirement for subluxation and medical diagnoses

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 ICD 10 code for subluxation?

Diagnoses Covered: 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.

Does Medicare cover chiropractic care for 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.

What is a secondary subluxation diagnosis?

The secondary diagnosis describes the secondary, neuromusculoskeletal condition relating to each primary subluxation. At least one of the MACs, First Coast Service Options covering Florida, doesn’t require that the primary subluxation diagnosis is included when billing.

What is the coverage of manual manipulation for subluxation?

The coverage is limited to manual manipulation for the treatment of subluxation. “Subluxation" is a term used by Chiropractors to describe a spinal vertebra that is out of position in comparison to the other vertebrae. § 40.4 Definition of Physician /Practitioner.

What is subluxation code?

Subluxation complex (vertebral) of lumbar region M99. 13 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM M99. 13 became effective on October 1, 2021.

What diagnosis codes does Medicare cover for chiropractic?

Doctors of chiropractic are limited to billing three Current Procedural Terminology (CPT) codes under Medicare: 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), and 98942 (five regions).

Does 98943 need a modifier?

Simply code it as 98943, no modifiers necessary. Make sure that you have an appropriate diagnosis code that reflects the extremity problem.

Do chiropractors use diagnosis codes?

Chiropractic medical billing involves error-free coding of diagnostic procedures with the correct ICD-10 codes. A chiropractor's first goal is to find out what is wrong and to make a diagnosis. The diagnosis helps to determine which type of treatment you need and what needs to be addressed.

What is manipulation of the spine to correct subluxation?

Spinal manipulation is also called spinal manipulative therapy. It's a technique where practitioners use their hands or a device to apply a controlled thrust (that is, a force of a specific magnitude or degree in a specific direction) to a joint of your spine.

What is the acronym for the system of documenting a subluxation?

The five diagnostic criteria for subluxation that constitute PARTS are listed in Table 1. Table 3. PARTS acronym. P – Pain/tenderness. A – Asymmetry/alignment.

Does Medicare cover code 98943?

NOTE: 98943: CMT, extraspinal, one or more regions, is not covered by Medicare.

Can 98941 and 97140 be billed together?

If you are billing 98941 along with 97140, you may find it very difficult to meet all of the criteria listed above. In addition to documentation, be sure your billing is consistent with the reason given for performing 97140 by pointing to the correct diagnosis code.

Does 97140 need a modifier?

CMS states that when billing 97140 and any of its paired codes for the same session or date, modifier 59 is only appropriate if the therapist performs the two procedures in distinctly different 15-minute intervals.

Is subluxation a diagnosis?

However, there is one diagnosis that's unique to chiropractic doctors. 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.

How is spinal subluxation diagnosed?

The most commonly used method was static palpation (mean score 6.6 +/- 1.1). Seven other methods, including pain description of the patient, orthopedic tests, motion palpation, visual posture analysis, leg length discrepancy, neurological tests and plain static X-rays had mean scores greater than 4.0.

Can a chiropractor make a medical diagnosis?

Chiropractors diagnose and treat many different spinal disorders that cause musculoskeletal or nerve pain. Similar to other types of doctors, a chiropractor performs a physical and neurological examination as part of his or her process of making an accurate diagnosis.

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 ...

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 is chiropractic subluxation?

The coverage is limited to manual manipulation for the treatment of subluxation. “Subluxation" is a term used by Chiropractors to describe a spinal vertebra that is out of position in comparison to the other vertebrae.

What is the CPT code for chiropractic manipulation?

Claims submitted for Chiropractic Manipulative Treatment (CMT) CPT codes 98940, 98941, or 98942, (found in Group 1 codes under CPT/HCPCS Codes) must contain an AT modifier or they will be considered not medically necessary.

What is CMS in healthcare?

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

Can you use CPT in Medicare?

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of CMS internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

What is a physician's signature?

Physician signature for progress notes and reports (handwritten, electronic). Initials if signed over a typed or printed name or accompanied by a signature log or attestation statement.

Why do contractors need to specify revenue codes?

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

How to identify asymmetry/misalignment?

Asymmetry/misalignment – Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following: observation (posture and gait analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc.

How long before subluxation can you take an X-ray?

X-ray is not required to demonstrate subluxation; however, may be used if chiropractor chooses. X-ray should be taken no more than 12 months prior to initiation of treatment or 3 months following initiation of treatment. Previous CT scan and/or MRI acceptable. X-ray must be maintained by the referring physician.

What is the relationship between spinal subluxation and symptoms?

The level of spinal subluxation must bear a direct causal relationship to the patient's symptoms and the symptoms must be directly related to the level of the subluxation that has been diagnosed.

What are the medical grounds for chiropractic manipulation?

Spinal axis aches, strains, sprains, nerve pains and functional mechanical disabilities of the spine are considered medically necessary therapeutic grounds for chiropractic manipulative treatment.

Does Medicare allow hand held devices?

Although Medicare does not recognize an extra charge for the device itself (no additional monies will be given), hand held devices are allowed (they must be controlled manually) Treatment should improve, arrest, or retard patient's condition. Results should occur within a reasonable and generally predictable time period.

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 subluxation code for sacroiliac joints?

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.

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 the 739 category in ICd 9?

This was the 739 category in ICD-9-CM. The inclusion terms for the 739 category include “segmental and somatic dysfunction” but make no mention of the word “subluxation.” Nonetheless, most private payers followed Medicare’s lead and accepted the 739 category as a justification to provide chiropractic manipulative treatment (the 9894X codes from CPT).

Why put subluxation in parentheses?

Throwing the word “subluxation” in there in parentheses lets the payers know that you are using the code they prefer, while still documenting what the patient really has.

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: