Billing maintenance therapy as active treatment
First Coast Service Options (FCSO) is estimating an improper payment error rate of 39 percent for chiropractic services in J9 (Florida, Puerto Rico and the US Virgin Islands) for the November 2011 CERT report.
These payment errors often involve the billing of chiropractic manipulation services that represent maintenance care.
Providers’ adherence to Medicare coverage guidelines for chiropractic services continues to be a significant issue in Florida, Puerto Rico, the U.S. Virgin Islands, and the nation.
Based on previous national findings, CMS requested that CERT perform a special study of chiropractic services in 2010. The CERT special study on chiropractic services yielded an overall error rate of 86.91 percent for J9.
The vast majority of the services reviewed were denied for insufficient documentation and for not being medically reasonable and necessary. Aside from documentation issues, the primary reason for payment errors in chiropractic services is maintenance therapy being billed as active treatment. This continues to be an issue, even after CMS implemented an acute treatment modifier to allow providers to differentiate maintenance from active treatment on submitted claims.
To help reduce and prevent improper payment errors, FCSO is reviewing data to identify beneficiaries receiving chiropractic services at routine intervals for extended periods of time and will develop beneficiary specific edits. FCSO will monitor the appeals data closely for these beneficiary specific edits, allowing ongoing edit adjustment when indicated.
FCSO has a Web-based training (WBT) module for chiropractic services available on FCSO University . In addition, helpful information and links to chiropractic services resources can be found on the FCSO provider website and the chiropractic services specialty page.
Also, a local coverage determination (LCD) was developed to assist providers in determining when Medicare will consider chiropractic manipulation of the spine medically reasonable and necessary. The LCD also provides guidance on documentation requirements.
To access the LCD for Florida click here, for Puerto Rico and the U.S. Virgin Islands click here.