Chiropractic Claims Rack Up $178 Million: OIG

Medicare inappropriately paid $178 million for chiropractic claims in 2006, according to a U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report.

Miscoded (generally upcoded) claims accounted for $11 million in improper payments and $46 million was inappropriately paid for undocumented claims, but maintenance therapy was the biggest offender, totaling $157 million in improper payments.

“Efforts to stop payments for maintenance therapy have been largely ineffective,” the OIG states in the May 2009 report.

The use of the AT modifier to indicate active/corrective treatment, provider education, frequency-based control edits (caps), and focused medical reviews are not working, agreed carrier staff, program safeguard contractors (PSC) staff, and medical reviewers for the study.

Medicare covers active/corrective manual manipulations of the spine to correct subluxations. The Medicare Benefit Policy Manual, Pub. 100-02, chapter 15, section 240.1.2, defines subluxation as “a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.” A chiropractic service, according to section 240.1.3 of the internet-only manual, “must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.”

When further improvement cannot reasonably be expected from continuing care and the services become supportive rather than corrective, the services are considered maintenance therapy. The Manual defines maintenance therapy as “a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition.”

Maintenance therapy is not considered a medically necessary chiropractic service and is not payable under Medicare. The OIG, however, identified 73,936 claims amounting to $2.4 million that were paid without the AT modifier.

Medicare Claims Requirements

Chiropractors are limited to billing three CPT® codes under Medicare:

  • 98940 Chiropractic manipulative treatment; spinal, one to two regions
  • 98941 … three to four regions
  • 98942 … five regions

The acute treatment (AT) modifier should be used to identify chiropractic services that are active/corrective treatment of an acute or chronic subluxation.

Specific documentation is also required. The seven general documentation requirements for initial visits are:

  1. Subluxation(s) demonstrated by X-ray or physical examination (exam must demonstrate at least two of the following four criteria: pain/tenderness, asymmetry/misalignment, abnormal range of motion, and tissue/tone changes);
  2. Diagnosis of subluxation(s);
  3. Patient history;
  4. Description of present illness;
  5. Treatment plan;
  6. Physical examination, and;
  7. Date of initial treatment.

The three general documentation requirements for subsequent visits are:

  1. Patient history;
  2. Physical exam, and;
  3. Documentation of treatment provided at each visit.

OIG Recommendations

In addition to recovering the $178 million in improper payments, the OIG recommended the Centers for Medicare & Medicaid Services (CMS) implement and enforce policies to prevent future payments for maintenance therapy, such as a new modifier for chiropractic claims to indicate the start of a new treatment episode and/or a cap on allowed chiropractic claims; consider expanding the CERT review from a single sampled claim to a treatment episode; and require carriers to withhold payment on reviewed claims when required documentation is absent or perform prepayment review of claims.

CMS agreed with the recommendations to review treatment episodes and recoup inappropriate payments but made no other commitments, stating only that the objective data required to impose a national cap on the number of chiropractice services does not currently exist.

Read the full report for complete study details. The full text of CMS’ comments can be found in Appendix D of the report.


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