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.

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A provider of service communicates important information about a patient’s episode of care by placing important information in Box 14 of the 1500 billing form. The date that is placed in this important field on the billing form communicates the first date of the current episode of care. This brief training will outline it’s importance in compliant billing.

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The Case Management Picture

Case management has its roots in the patient’s clinical presentation and the doctor’s training and expertise. Doctors have a fiduciary responsibility to evaluate patients and determine the whole clinical picture to the best of their ability.

The patient evaluation process is quite linear. The doctor begins by gathering the patient’s history and documenting the chief complaint and then s/he follows the patient’s lead. The rest of the journey might look something like the following. The doctor must follow the steps illustrated on the right.

1. 1. Initial data is gathered via patient paperwork that details his/her previous medical history, or through a short interview conducted by a team member. Ideally, the doctor reviews this data before meeting with the patient for the first time to get a sense of the direction s/he wants to take during the patient interview process.
   2. Once the history is established, the doctor follows-up with a more in-depth consultation, asking general health questions, conducting a review of systems, and completing a thorough evaluation of the chief complaint including Onset, Provocation/Palliation, Quality, Region/Radiation,  Severity, and Time.
   3. After the doctor has completed the history and consultation, s/he begins to formulate a differential diagnosis. Now, these impressions and the history must drive the examination choices. Based on the doctor’s conclusions about the patient’s condition, s/he selects proactive orthopedic and neurological tests to prove or disprove those theories.
   4. When all of the facts about the patient’s physical findings are gathered, the doctor must determine whether there is enough evidence for a conclusive decision about a diagnosis, or if further diagnostic tests are necessary.
   5. The definition of the problem (or the diagnosis of the condition/subluxation) is defined.
   6. A written treatment plan/solution to the defined condition is established.

The treatment plan should include details of the doctor’s recommendations including tissue-specific solutions for the patient’s presenting problem. It is especially important to define the functional deficits that will be addressed through this treatment plan and the functional goals that are targeted in order to achieve a specific result from this treatment when a third-party payer is involved.

The doctor should present the patient with a verbal report of his/her:

• • Findings
  • Recommendations
  • Expected outcomes from the treatment plan
  • Any other options the patient may have (including taking no action at all)

The doctor should inform the patient of the probable outcomes for each of those options so s/he can make an informed decision about how to proceed. The discussion should include information about the patient’s financial responsibility, such as:

• • Billing third-party payers when appropriate
  • Legal means for assistance with payment plans
  • Indigence policies
  • Professional courtesy policies

The intention is to be sure that the patient is clear about the recommendations and to support the patient as you move forward with the recommended care. Remember, the patient always has the right to refuse treatment. If you do a good job of explaining your recommendations, any alternatives, and the potential outcomes for those alternatives including taking no action at all, your patient will feel confident making the decision to proceed.

Usually, patients choose the doctor’s best recommendation. Once the patient has agreed to proceed with a course of care, the doctor is responsible for helping the patient successfully complete that care. Patients that follow through with the recommendations nearly always recover and stay well, and that is the most satisfying part of practice!

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Download Support Tool

This tool is one of the most useful and important tools in the KMC University Curriculum. Although designed for Medicare using Medicare terminology, the flowcharts apply to any type of third-party insured patient.

An important question is posed as a patient presents to the office: “Is this patient currently in an active episode of care?” If yes, the path is quite simple. If not, follow along the middle and right side of the matrix and note the additional decision-making that is necessary here.

While this tool is not meant to be absolute, it guides providers in the questions to consider when determining whether a visit will be deemed medically necessary or not. Download and review it and save it to your Medicare training materials. You may also wish to laminate a copy or place one in a sheet protector for easy reference.

The KMC University Medicare Decision Making Matrix

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Recognize the Differences Between Active and Maintenance Care

One of the most difficult concepts for providers to grasp is the fine line that exists between the necessity of active treatment and when the care would be deemed maintenance. This distinction is critically important because declaring a visit to be medically necessary, therefore billable to and payable by Medicare, has compliance implications. At KMC University, we believe that this concept…knowing this difference, is one of the most important pieces of business knowledge that providers and team members can know. It’s the difference between risk and safety. This graphic image highlights several important facts that distinguish active care from maintenance care.

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Clinically appropriate care is that recommended treatment that is within the doctor’s scope of practice and appropriate for the patient but may not meet the medical necessity guidelines of a third-party payer. Patients have every right to receive this type of care, but both provider and patient must be aware that it is likely paid by the patient. Medically necessary care is both clinically appropriate and in line with the definitions set forth by the payer. A keen understanding of these differences between these two is one of the most important tenets of healthcare compliance. This brief training outlines the differences and starts you on your way to a better understanding of these two important definitions.

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