CMS MAC NOVITAS Published LCD L34816 for Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma, New Mexico and revised for the states of Pennsylvania, New Jersey, Maryland, Delaware and District of Columbia to update the reference to L27480 to L34816 to reflect a maximum of twelve (12) chiropractic manipulation treatments per calendar month and thirty (30) chiropractic manipulation treatments per calendar year.
This LCD imposes both diagnostic limitations and total service limitations to chiropractic care. This is the “first” such restrictions placed on Chiropractic care and to our knowledge, J10 MAC B (Alabama, Georgia, Tennessee) is the only other policy with annual service restriction
L32342 limits utilization to 25 visits per year without assignment to the groups. (This policy, as are many other carrier policies on Chiropractic are will be reviewed in 2014
| LCD TitleChiropractic Services | Original Effective DateFor services performed on or after 07/24/2014 |
Utilization Guidelines
The following number of chiropractic manipulation services per beneficiary is considered reasonable and necessary if the medical record supports the service regardless of the nature of the visit (i.e., acute injury, acute exacerbation).
Twelve (12) chiropractic manipulation treatments per calendar month. And, Thirty (30) chiropractic manipulation treatments per calendar year.
This LCD imposes diagnosis limitations that support diagnosis to procedure code automatic denials. Coverage diagnoses are displayed in four groups in this policy as described in the indications and limitations section of this policy. If 30 visits are performed for group D, then this will also serve as the maximum number of visits for the year.
Local Coverage Article: Chiropractic Services (A47798)
Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.
Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.
This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulation services per beneficiary per calendar year. Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.
Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:
- Twelve (12) chiropractic manipulation treatments for Group A diagnoses.
- Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.
- Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.
- Thirty (30) chiropractic manipulation treatments for Group D diagnoses.
As per the definitions supplied in LCD L34816, all treatments must be categorized as either acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either “acute” or “chronic” (e.g., an identifiable re-injury would fall under acute).
Group 1 Codes
- 98940 Chiropract manj 1-2 regions
- 98941 Chiropract manj 3-4 regions
- 98942 Chiropractic manj 5 regions
Group 1 : The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:
Primary Diagnosis Codes (DrR=These are always your primary diagnoses)
Covered for: Group 1 Codes
- 739.0 NONALLOPATHIC LESIONS OF HEAD REGION NOT ELSEWHERE CLASSIFIED
- 739.1 NONALLOPATHIC LESIONS OF CERVICAL REGION NOT ELSEWHERE CLASSIFIED
- 739.2 NONALLOPATHIC LESIONS OF THORACIC REGION NOT ELSEWHERE CLASSIFIED
- 739.3 NONALLOPATHIC LESIONS OF LUMBAR REGION NOT ELSEWHERE CLASSIFIED
- 739.4 NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED
- 739.5 NONALLOPATHIC LESIONS OF PELVIC REGION NOT ELSEWHERE CLASSIFIED
Group 2 Secondary Diagnosis Codes
Group A Diagnoses Covered for: (Twelve (12) chiropractic manipulation treatments)
Group 2 Codes
- 307.81 TENSION HEADACHE
- 719.48*PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES
- 723.1 CERVICALGIA
- 724.1 PAIN IN THORACIC SPINE
- 724.2 LUMBAGO
- 724.5 BACKACHE UNSPECIFIED
- 724.8 OTHER SYMPTOMS REFERABLE TO BACK
- 728.85 SPASM OF MUSCLE
- 784.0 HEADACHE
- When using 719.48, you must specify spine as the site.
Group 3 : Group B Diagnoses Covered for: Eighteen (18) chiropractic manipulation treatments
Group 3 Codes
- 720.1 SPINAL ENTHESOPATHY
- 721.0 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY
- 721.1 CERVICAL SPONDYLOSIS WITH MYELOPATHY
- 721.2 THORACIC SPONDYLOSIS WITHOUT MYELOPATHY
- 721.6 ANKYLOSING VERTEBRAL HYPEROSTOSIS
- 721.90 SPONDYLOSIS OF UNSPECIFIED SITE WITHOUT MYELOPATHY
- 721.91 SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY
- 724.79 OTHER DISORDERS OF COCCYX
- 729.1 MYALGIA AND MYOSITIS UNSPECIFIED
- 729.4 FASCIITIS UNSPECIFIED
- 846.0 LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN
- 846.1 SACROILIAC (LIGAMENT) SPRAIN
- 846.2 SACROSPINATUS (LIGAMENT) SPRAIN
- 846.3 SACROTUBEROUS (LIGAMENT) SPRAIN
- 846.8 OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN
- 847.0 NECK SPRAIN
- 847.1 THORACIC SPRAIN
- 847.2 LUMBAR SPRAIN
- 847.3 SPRAIN OF SACRUM
- 847.4 SPRAIN OF COCCYX
Group 4: Group C Diagnoses Covered for: Twenty-four (24) chiropractic manipulation treatments
Group 4 Codes
- 353.0 BRACHIAL PLEXUS LESIONS
- 353.1 LUMBOSACRAL PLEXUS LESIONS
- 353.2 CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED
- 353.3 THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED
- 353.4 LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED
- 353.8 OTHER NERVE ROOT AND PLEXUS DISORDERS
- 722.91 OTHER AND UNSPECIFIED DISC DISORDER OF CERVICAL REGION
- 722.92 OTHER AND UNSPECIFIED DISC DISORDER OF THORACIC REGION
- 722.93 OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION
- 723.0 SPINAL STENOSIS IN CERVICAL REGION
- 723.2 CERVICOCRANIAL SYNDROME
- 723.3 CERVICOBRACHIAL SYNDROME (DIFFUSE)
- 723.4 BRACHIAL NEURITIS OR RADICULITIS NOS
- 723.5 TORTICOLLIS UNSPECIFIED
Group 5 : Group D Diagnoses Covered for: Thirty (30) chiropractic manipulation treatments
Group 5 Codes
- 721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY
- 721.41 SPONDYLOSIS WITH MYELOPATHY THORACIC REGION
- 721.42 SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION
- 721.7 TRAUMATIC SPONDYLOPATHY
- 722.0 DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY
- 722.10 DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY
- 722.11 DISPLACEMENT OF THORACIC INTERVERTEBRAL DISC WITHOUT MYELOPATHY
- 722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC
- 722.51 DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC
- 722.52 DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC
- 722.6 DEGENERATION OF INTERVERTEBRAL DISC SITE UNSPECIFIED
- 722.81 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION
- 722.82 POSTLAMINECTOMY SYNDROME OF THORACIC REGION
- 722.83 POSTLAMINECTOMY SYNDROME OF LUMBAR REGION
- 724.01 SPINAL STENOSIS OF THORACIC REGION
- 724.02 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION
- 724.03 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION
- 724.3 SCIATICA
- 724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED
- 724.6 DISORDERS OF SACRUM
- 738.4 ACQUIRED SPONDYLOLISTHESIS
- 756.11 CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION
- 756.12 SPONDYLOLISTHESIS CONGENITAL
- 839.01 CLOSED DISLOCATION FIRST CERVICAL VERTEBRA
- 839.02 CLOSED DISLOCATION SECOND CERVICAL VERTEBRA
- 839.03 CLOSED DISLOCATION THIRD CERVICAL VERTEBRA
- 839.04 CLOSED DISLOCATION FOURTH CERVICAL VERTEBRA
- 839.05 CLOSED DISLOCATION FIFTH CERVICAL VERTEBRA
- 839.06 CLOSED DISLOCATION SIXTH CERVICAL VERTEBRA
- 839.07 CLOSED DISLOCATION SEVENTH CERVICAL VERTEBRA
- 839.08 CLOSED DISLOCATION MULTIPLE CERVICAL VERTEBRAE
- 839.20 CLOSED DISLOCATION LUMBAR VERTEBRA
- 839.21 CLOSED DISLOCATION THORACIC VERTEBRA
- 839.41 CLOSED DISLOCATION COCCYX
- 839.42 CLOSED DISLOCATION SACRUM
- 953.0 INJURY TO CERVICAL NERVE ROOT
- 953.1 INJURY TO DORSAL NERVE ROOT
- 953.2 INJURY TO LUMBAR NERVE ROOT
- 953.3 INJURY TO SACRAL NERVE ROOT
- 953.4 INJURY TO BRACHIAL PLEXUS
- 953.5 INJURY TO LUMBOSACRAL PLEXUS
- 953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS
Notify your billing people and managers that they will see the following denials on your RA/EOBs.
These are the Edits and suggested MSN and RA messages.
Do not pay for manual manipulation of the spine in treating conditions other than those indicated in Pub. 100-02, Benefits Policy Manual, Chapter 15, Section 240.1.3 and deny claims for treatment of any condition not reasonably related to a subluxation involving vertebrae at the spinal level specified. Use the MSN 15.4, “The information provided does not support the need for this service or item.” For the RA, use the Claim Adjustment Reason Code 50, “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.”
Edit to verify that the claim has the primary diagnosis of subluxation. Use the MSN 15.4, “The information provided does not support the need for this service or item.” For the RA, use the Claims Adjustment Reason Code B22, “This payment is adjusted based on the diagnosis.”
One other little thing ….. Initial Treatment Date on Chiropractic Claims
Novitas also reminds providers that according to the Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 220 all chiropractic claims must contain the date of initial treatment or date of exacerbation of the existing condition so consistent with Medicare guidelines, Novitas will require that all chiropractic claims contain the initial treatment date or the date of exacerbation of the existing condition effective for dates of service July 24, 2014 and after.
They will edit to verify that the date of the initial visit or the date of exacerbation of the existing condition is entered in Item 14 of Form CMS-1500. Use the MSN 9.2, “This item or service was denied because information required to make payment was missing.” For the RA, use the Claims Adjustment Reason Code 16, “Claim/service lacks information which is needed for adjudication.
Richard Matthews DC DACNB says:
Thanks for the clearly written explanation! We’ve been following this latest edict for about two years, when I first got wind of it based on previous regions under Novitas rule. Here’s one of the major issues though: Patients go to one chiropractor, use up their 12/30 limitations, then present to another chiropractor and do not reveal their previous visits to the second chiropractor. Medicare does not disclose previous visits to a previous chiropractor, effectively making it impossible to verify true remaining available coverage. Also, there does not seem to be a “category” for patients that used up their 12/30 benefits then get a new acute injury. Are they “statutorially maintenance care”? Medicare does not seem to have an answer to this. Hard to tell someone with a fresh injury that it isn’t covered because it is deemed maintenance care. They go down the road to another chiro and try again!