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“More than 80% of the money that Medicare paid to chiropractors in 2013 went for medically unnecessary procedures

That sentence opened an October 19th Wall Street Journal article about a new US government audit of chiropractic Medicare claims. The audit entitled, Hundreds Of Millions In Medicare Payments For Chiropractic Services Did Not Comply With Medicare Requirements, was performed by the US Department of Health and Human Services, Office of Inspector General (HHS/OIG).

CMS guidance requires chiropractors to place the AT (Acute Treatment) modifier on a claim when providing active/corrective treatment. However, the new study highlighted the fact that inclusion of the AT modifier does not always indicate that the service provided was reasonable and necessary.

“On the basis of our sample results, we estimated that $358.8 million, or approximately 82 percent, of the $438.1 million paid by Medicare for chiropractic services was unallowable.”

It is important to note that while DC’s provided 17,014,775 (AT) treatments to Medicare patients, this new audit is based upon a random sample of only 105 claims (sample size = 0.000006%). Readers may recall a prior 2005 OIG report that identified a high error rate on chiropractic claims. That report concluded:

“…as chiropractic care for a beneficiary extended beyond 12 treatments in a year, it became increasingly likely that individual services were medically unnecessary, with an even greater likelihood that services were medically unnecessary after 24 treatments.”

CMS has indicated that they will act upon two proposed OIG recommendations from the new report. Although CMS does not currently intend to place a formal “hard” limit on the number of chiropractic visits, they will “determine a reasonable number of chiropractic services that are necessary…and implement a system edit to identify services for review in excess of that number”. CMS will also “improve education of chiropractors on… the proper use of the AT modifier”.

CMS stated that pre-authorization will be required for chiropractic services furnished on or after January 1, 2017, by “a chiropractor whose pattern of billing is aberrant and for episodes of treatment that included more than 12 services”.

Take home point- Medicare does not allow the use of the AT modifier if:

  • A “subluxation” was not documented and treated. The Benefit Manual states that a subluxation of the spine must be demonstrated by an x-ray or by physical examination and provides specific information that must be documented (PART documentation).
  • Treatment is maintenance- i.e. “a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life or therapy that is performed to maintain or prevent deterioration of a chronic condition, or would not be expected to result in improvement within a reasonable and generally predictable period of time”.
  • The patient has reached MMI. “When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.”

As Medicare and other carriers continue to define value-based care, providers must seek to provide the most clinically beneficial and cost-effective treatments. Chiropractors have an unprecedented opportunity to lead the way- it begins today with you and I.

Reference
https://oig.hhs.gov/oas/reports/region9/91402033.pdf

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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