Active vs. Maintenance Care FAQs

Q: If a Medicare patient moves from Medical Necessity treatment to Wellness and we have him/her sign an ABN, are we required to continue to bill Medicare with the appropriate modifier or can we convert the patient to cash?
A: The ABN offers three options at the bottom of the form. If the patient selects:

Option 1 –  you must bill
Option 2 –  you cannot bill it to Medicare
Option 3 –  you can either elect to charge your patients the allowable/limiting fee set forth by Medicare or you can elect to charge the full office fee

Regardless of the option you choose, you must be consistent in how you charge the patient. We recommend that you create a policy stating that during maintenance you charge the full fee or the allowable/limiting fee.
Q: Does Medicare restrict the number of visits a patient is allowed each year?
A: Medicare does not limit patients to a predetermined number of visits but they do require that medical necessity be clearly defined in the documentation.  All CMT billed to Medicare as Active Treatment (AT) must meet the true definition of acute or chronic care. You must have a written plan of care that assumes the patient will see functional improvements to his/her condition.

According to Medicare, Medical Necessity is when the patient has a significant health problem in the form of a neuromusculoskeletal condition that necessitates treatment; and, the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and offer a reasonable expectation of recovery or improvement of function. It is important to become very familiar with the Local Coverage Determination (LCD) issued by your Medicare Administrative Contractor (MAC). Some MACs have outlined guidelines that may or may not include recommended caps for visits based on a particular diagnosis or condition, but these are not set in stone.

Medicare describes the following differences between Acute, Chronic and Maintenance Care:

Acute Care – When the patient is being treated for a new injury identified by X-ray or physical exam as specified above. The chiropractic manipulation is expected to result in an improvement in, or arrest the progression of the patient's condition.

Chronic Care – When the patient’s condition is not expected to significantly improve or resolve through further treatment but the continued therapy is expected to result in some functional improvement. Once clinical status is stable for a given condition, and no additional objective clinical improvements are anticipated, further manipulative treatment is considered maintenance therapy and is not covered.

Maintenance Care – A treatment plan that seeks to: prevent disease, promote health, and/or prolong and enhance the quality of life. It can also be therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement is not expected through ongoing care, and the chiropractic treatment is supportive rather than corrective in nature, the treatment is considered maintenance therapy. Chiropractic maintenance therapy is not considered medically reasonable or necessary under the Medicare program and is not covered.

Q:

 When you are treating two regions of the spine in an active care program, but you are also delivering maintenance care to other regions, what can you do?
A: According to Medicare guidelines you can only bill Medicare for what is medically necessary.  That means you can’t charge separately for maintenance care.  You should document the care and then only bill Medicare for the appropriate levels. This is not considered “gifting” as you are just adhering to Medicare guidelines.
Q: I'm having difficulty determining what maintenance is. If I have a patient that I see approximately every 3-4 weeks because that is when his/her pain returns, is s/he considered maintenance?
A: Maintenance is considered care provided to a patient that doesn’t improve function and that is provided only to prevent the recurrence of or to maintain a condition.  If, by evaluating a patient, you determine that care will achieve measurable functional improvement then it would be considered active care and not maintenance.

A patient who presents on a routine basis (e.g., once-per-month) is often considered a maintenance patient if his/her condition doesn’t meet the Medical Necessity Guidelines for active care. However, frequency does not always determine whether medical necessity can or cannot be supported.

Note: Other documentation guidelines must also be met including: provider recommendations, treatment plan, etc.
Q: I have a patient with chronic pain that I see once a month to prevent the condition from deteriorating--is this considered wellness, maintenance, or active care?
A: It is probably wellness or maintenance care and the patient would have full financial responsibility for his/her care.  According to Medicare “Maintenance therapy includes services that prevent disease, promote health, prolong and enhance the quality of life, or that maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot be reasonably expected from continuous, ongoing care and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A)”.

The patient should sign a Mandatory ABN form for chiropractic manipulations, and claims should be billed to Medicare with a GA modifier rather than an AT modifier if the patient selects Option 1 at the bottom of the form.

Typically, if patients are coming in occasionally for a “tune up”, the doctor doesn’t have to conduct an exam each time.  Ask the patient if s/he is coming in with a new complaint.  If yes, an exam (which means billing an E/M code) is warranted.
Q: I have a question regarding Medicare dx codes. We are billing a set of dx codes and they are coming back denied as not medically necessary.  I used S13.4XXD with the subluxation code.
A: It is extremely important to be familiar with the Local Coverage Determination (LCD) for chiropractic services issued by your Medicare Administrative Contractor (MAC).  You will find that some jurisdictions release a list of covered secondary diagnoses. In many of the LCD’s, S13.4XXA is a recognized diagnosis. You used S13.4XXD which indicates to Medicare that the services rendered were more maintenance or preventative in nature.

In this scenario, this patient appears to be experiencing a new onset of an “old” injury.  Since this is a new onset, you should conduct an examination, document it appropriately, and consider using an “A” for the 7th character. The 7th character “A” is used to report a patient who is currently having complaints that should be treated in an active or corrective manner.