Practice Management Alert

Question: We are a local chiropractic practice that often receives referrals from local orthopedists. One of our recent referrals for a patient with chronic back pain was denied because the services did not improve the patient’s symptoms. This explanation still has me puzzled, though. Can you shed some light on the reason for the denial?

Arkansas Subscriber

Answer: “Chronic pain” is the key to the denial. Medicare distinguishes the two different areas of chiropractic care as acute and chronic. In order for the claim to be accepted and the referral to be valid, the pain must be acute.

In order to diagnose acute pain, the following conditions must be met:

• An acute subluxation of the spine must be present.
• The services that will be rendered from chiropractic care must be reasonable and medically necessary.
• The care given will decrease or arrest the pain from the subluxation of the spine.
• The condition must be well-documented with either x-rays and the pain, asymmetry, range of motion and tissue tone (P.A.R.T.) exam, or both.
• The chiropractor must be deemed qualified by the state he or she received licensure.

Also: Make sure you monitor all local coverage determination (LCDs) to ensure that you’re following all of the Medicare administrative contractor (MAC) mandates.

Denials may happen: Unfortunately, denials and audits are quite frequent regarding chiropractic referrals and care. This is mostly due to the gray area that exists between acute and chronic, maintenance therapy, and the lack of adequate procedures.

Update: In a report published Aug. 17, 2016, the Office of Inspector General (OIG) outlined billing problems related to a Michigan chiropractor. They found 92 of 100 sampled claims incorrect and not compliant with current Medicare rules. The OIG records show the financial result was an overpayment of almost $340,000.

The three main reasons for the denials were:

• Documentation did not support the claims.
• The care was maintenance therapy, and therefore not covered.
• The manual manipulation of the spine would not or could not improve the symptoms and diagnosis.

Final clarification. Both acute and chronic subluxation are covered under Medicare, but once the treatment for chronic pain becomes routine, and the patient shows no improvement from the treatment, that is considered maintenance therapy and is not covered under the chiropractic regulations.

“A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement,” MLN Matters® article SE1602 says. “Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.”

Resource.  To read MLN Matters® article SE1602, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1602.pdf.