Deeper Than the Headlines: Chiropractic Services

Chiropractic services are regular targets of audits by government agencies including Medicare, Medicaid, and the OIG. In calendar years (CYs) 2012 and 2013, Medicare Part B accepted approximately $1.4 billion in chiropractic services to Medicare beneficiaries nationwide. And previous OIG reviews found that Medicare inappropriately paid for chiropractic services that were either medically unnecessary, incorrectly coded, or undocumented.

What Constitutes a Covered Chiropractic Service?

Chiropractic services focus on the body’s main structures—the skeleton, the muscles, and the nerves. Chiropractors make adjustments to these structures, particularly the spinal column. Most patients seek chiropractic care for back pain, neck pain, and joint problems. The most common therapeutic procedure performed by chiropractors is known as spinal manipulation, also called chiropractic adjustment. The purpose of spinal manipulation is to restore joint mobility by manually applying a controlled force into joints that have become restricted in their movement as a result of a tissue injury.

Medicare Part B covers chiropractic services provided by a qualified chiropractor. Medicare requires that chiropractic services be reasonable and necessary for the treatment of a beneficiary’s illness or injury, and Medicare limits coverage of chiropractic services to manual manipulation (i.e., by hand) of the spine to correct a subluxation (when spinal bones are misaligned). Chiropractors may also use manual devices to manipulate the spine. To substantiate a claim for manipulation of the spine, the chiropractor must specify the precise level of subluxation. Depending on the number of spinal regions treated, chiropractors may bill Medicare for chiropractic manipulative treatment using one of three Current Procedural Terminology (CPT) codes: 98940 (for treatment of one to two regions), 98941 (for treatment of three to four regions), and 98942 (for treatment of five regions). The CPT code for extraspinal chiropractic manipulative treatment (98943) is not covered by Medicare.

Audit Results of a Queens Chiropractor

After analyzing CYs 2012 and 2013 Medicare claims data, the OIG audited a chiropractic practice located in Queens, New York, which was the third highest-paid provider of Medicare chiropractic services in the state during that time period.

During the audit period of January 1, 2012, through August 31, 2014, the Queens Chiropractor employed one additional chiropractor. The Medicare claims data showed that all of the chiropractic services provided by the Queens Chiropractor were billed with the Active Treatment (AT) modifier, which defines the difference between active treatment and maintenance treatment. The Queens Chiropractor did not submit any claims for chiropractic services with CPT code 98942, the code with the highest Medicare fee schedule amount. Rather, the Queens Chiropractor billed the majority (98 percent) of services with CPT code 98940, the code with the lowest fee schedule amount. The remaining services were submitted with CPT code 98941, the code with the second-highest fee schedule amount.

The OIG’s review covered 6,768 claims for which the Queens Chiropractor received Medicare reimbursement totaling $650,470 for 28,200 chiropractic services provided during the audit period. Of those services, they reviewed a random sample of 100 claims.

According to the OIG’s review, nearly all Medicare Part B payments to the Queens Chiropractor did not comply with Medicare requirements. Of the 100 sample claims for which the Queens Chiropractor received Medicare Part B reimbursement, 95 did not comply with Medicare requirements, the remaining 5 did. Specifically, 92 claims contained chiropractic services that were not medically necessary, 91 claims contained chiropractic services that were not sufficiently documented, and for 2 claims, there was no documentation to support the chiropractic services billed to Medicare.

As a result, the OIG concluded the Queens Chiropractor received $8,468 in unallowable payments. On the basis of their sample results, the OIG estimated that the Queens Chiropractor received un-allowable Medicare payments of at least $518,821 provided during the audit period. Put another way, 80% of their submitted claims should not have been allowed.

Services Not Medically Necessary

According to the OIG, Medicare regulations do not allow for payment of any expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Additionally, Medicare Part B pays for a chiropractor’s manual manipulation of the spine to correct a subluxation only if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is an appropriate treatment. Chiropractic maintenance therapy is not considered medically reasonable or necessary. Therefore, it is not payable under the Medicare program. Additionally, any manipulative services that are provided must have a direct therapeutic relationship to the patient’s condition, and the patient must have a subluxation of the spine. Finally, the chiropractor should be afforded the opportunity to effect improvement or arrest or impede deterioration of the condition within a reasonable, and generally predictable, period of time. Of the 100 sample claims, 92 of the claims contained chiropractic services that were not medically necessary.

The results of the medical review indicated that services on these claims did not meet one or more of the Medicare requirements related to medical necessity:

• Manual manipulation of the spinal subluxation would not be expected to result in improvement within a reasonable and generally predictable period of time (90 claims).
• Manual manipulation of the spinal subluxation was maintenance therapy or was not appropriate for treatment of the beneficiary’s condition (90 claims).
• Subluxation of the spine was not present or was not treated with manual manipulation (two claims)

In one example, the Queens Chiropractor received payment for chiropractic services provided to a 69-year-old Medicare beneficiary. The medical review contractor determined that the medical records did not support the medical necessity of the chiropractic services because the beneficiary was receiving maintenance therapy rather than active treatment. During the audit, the Queens Chiropractor received Medicare reimbursement totaling $2,141 for 94 chiropractic services provided to this 69-year-old Medicare beneficiary.

Based on their findings, the OIG recommended that the Queens Chiropractor:

• Refund to the Federal Government the portion of the estimated $518,821 in identified improper payments for claims incorrectly billed that are within the reopening period.
• Of the estimated $518,821 in improper payments for claims that are outside of the Medicare reopening period, the Queens Chiropractor must exercise reasonable diligence to identify and return improper payments in accordance with the 60-day rule and identify any returned improper payments as having been made in accordance with this recommendation.
• Exercise reasonable diligence to identify and return any additional similarly improper payments outside of the audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.
• Develop policies and procedures to ensure that any future chiropractic services billed to Medicare comply with Medicare requirements.

The Queens Chiropractor disagreed with many of the OIG’s findings. The comments of their disagreements, as well as the OIG’s response to these comments, are included in the report.