Medicare Archives

Medical Necessity vs. Clinical Appropriateness

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…

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Medicare’s Definition of Medical Necessity

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…

What is Medical Necessity?

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…

Medicare’s Definition of Medical Necessity

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…

Medicare Benefit Policy Manual – Section 240, Chapter 15

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…

Using PART as Part of your ROV Documentation

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…