Every payer has a definition of medical necessity and Medicare is no exception. Medicare Administrative Contractors (MACs) release a Local Coverage Determination (LCD) where they provide healthcare providers of all specialties their rules and definitions so they can determine if the care they are providing to their patients is payable. The following definitions pertaining to Chiropractic care come directly from Medicare:
| Term |
Definition |
| Medical Necessity |
The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition while providing a reasonable expectation of recovery or improvement of function |
| 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 |
When the patient’s condition is not expected to significantly improve or be resolved with further treatment, but the continued therapy is expected to result in some functional improvement. Once the clinical status is stable for a given condition, and no additional objective clinical improvements are expected, further manipulative treatment is considered maintenance therapy and is not covered. |
| Maintenance |
A treatment plan that seeks to prevent disease, promotes health, and prolongs and enhances the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement is not expected from continuous, 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 payable. |
| Acute Exacerbation |
A temporary, but marked deterioration of a patient’s condition that is causing significant interference with activities of daily living due to an acute flare-up of a previously treated condition. The patient’s clinical record must specify the date of occurrence, nature of the onset, or other pertinent factors that support the medical necessity for treatment. As with an acute injury, treatment should result in an improvement of or an arrest of the deterioration in a reasonable period of time. |
| Chronic Exacerbation |
Represents an acute change that is a marked deterioration of the patient’s condition and that is causing significant interference with activities of daily living. “Active treatment” can only occur as long as the patient is achieving significant clinical improvement. |
Establishing Medical Necessity
Properly trained and licensed healthcare professionals, such as Doctors of Chiropractic, can diagnose and develop a treatment plan for their patients. Their decision-making skills allow them to determine the frequency of the patients’ visits and what services the patients will receive. As long as the doctor exercises good judgement and meets or exceeds the standard of care, all of the care is clinically appropriate. However, not all care meets the definition of medically necessary. The definition of medically necessary care varies from payer to payer. They establish the definition.
For Medicare, there must be a documented spinal subluxation that is causing a neuromusculoskeletal condition. The ability to improve the patient’s function through treatment is also a requirement. The best way to prove medical necessity is through the provider’s documentation which includes the initial intake, history, exam, daily treatment notes, a treatment plan with measurable functional goals, and possibly imaging. When medical necessity is established, it is called active treatment in Medicare and is designated with an AT modifier when billing. The patient’s care is deemed maintenance care when these criteria are not met. Only spinal manipulations deemed active treatment are payable by Medicare.
The essence of medical necessity in Medicare is being able to prove that a subluxation exists, since the only coverage for chiropractic treatment is manual manipulation of the spine to correct a subluxation. However, a subluxation that is not associated with a secondary neuromusculoskeletal condition, and/or is not causing a loss of function may not…
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Medicare Benefit Policy Manual
Medicare publishes helpful documents and alerts to keep providers in the know about important topics. The Benefit Policy Manual is the rulebook that must be followed for Medicare. Chapter 15, and Section 240 is the section that is devoted to the policy guidelines for chiropractic coverage and care. This Reference Document is only Section 240, which is 10 pages out of about 300 in this Chapter. Download, study, and save this document in your Medicare training materials as an essential reference for chiropractic Medicare.
Medicare Benefit Policy Manual – Section 240, Chapter 15
Documenting PART During Routine Office Visits
The PART Process initials are an acronym for the required elements of examination that quantify the existence of a subluxation to meet Medicare requirements. The elements of PART are Pain, Asymmetry or Misalignment, Range of Motion Abnormalities, and Tissue Tone Changes. These elements are generally present in the initial examination by the chiropractor at the beginning of an episode of care. Therefore, the subluxation is established during the initial visit of the episode for that treatment plan.
There is some discrepancy in the language published by the Center for Medicare and Medicaid Services (CMS) vs. the language published by many Medicare Administrative Contractors (MAC) regarding the requirement to demonstrate PART on each subsequent visit of an episode of care. However, because the elements of PART are usually included in standard objective findings during a subsequent visit anyway, it’s a simple way to better document those findings day to day. Therefore, we recommend that you not only include the changes since the last visit in the objective findings but also document 2 of the 4 elements of PART, one being Asymmetry or Range of Motion. The following table illustrates the thought process or considerations that may help in document PART on a routine visit basis.
| Documenting PART During Routine Office Visits |
| P |
Pain |
- Pain can be expressed in pain scale numbers or illustrated as painful upon palpation
- Pain assessments should include quality descriptors
|
| A |
Asymmetry/Misalignment |
- Asymmetry may be assessed each visit with updated segmental listings
- Posture may be reassessed each visit with specific notations
- Comment on how these assessments of asymmetry and posture differ from the previous or initial visit
|
| R |
Range of Motion |
- Assessment of regional or segmental range of motion (ROM) limitations should be noted in your findings
- ROM may be assessed manually or with a digital goniometer
- Asymptomatic, but compensatory regions may be assessed and documented
- Document changes in ROM from visit to visit to show progression or lack thereof
|
| T |
Tissue Tone Changes |
- Palpatory tissue and tone changes may be described as hyper- or hypo- tonicity with changes noted from visit to visit
- Spasticity may be documented when present
- Grading these changes as mild, moderate, or severe can help document the patient’s improvement, or lack thereof
|
Using Clinical Judgement to Document PART Medicare requires that medical necessity be proven using the components of PART: Pain, Asymmetry, Range of motion, and Tissue tone changes. Two of these four elements must be present, and one must be Asymmetry or Range of motion. These are findings that are usually discovered during the initial evaluation…
This content is reserved for our student Chiropractors in training!