Help your patients understand the benefits of paying for wellness care.
IF YOU SPEND ANY AMOUNT OF TIME READING THE VARIOUS THREADS AND CONVERSATIONS ON FACEBOOK, LinkedIn, and other online chiropractic groups, you know that this profession has wide and varying opinions.
Some feel strongly that chiropractic is a lifelong need, where wellness care is incorporated into every patient’s treatment plan. Others believe in the “pain relief” paradigm of chiropractic, and as a result they discharge patients who return only when they have pain.
Chiropractic is a large umbrella beneath which everyone’s philosophy can fit for the good of the patient. One of the points of contention, however, is whether third-party payers can be billed for wellness care.
Operating your business within a world of third-party reimbursement automatically subjects you to myriad rules and regulations. Among them is the premise that when you bill for services in your practice, you are charging for medically necessary care, not maintenance care.
For example: Independence Blue Cross (IBC) has published this clarification of the definition of “maintenance therapy” as part of their Chiropractic Billing Guide:
“The continuation of care and management of the patient when the therapeutic goals of a treatment plan have been achieved, no additional functional improvement is apparent or expected to occur, the provision of services for a condition ceases to be of therapeutic value, and the service is no longer medically appropriate/necessary.”1
Medicare has published its own definition of maintenance care as follows:
“Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. 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.” 2
Medicare’s maintenance definition can be divided into two categories. Break down the definition by looking at the first half: “services that seek to prevent disease, promote health and prolong and enhance the quality of life,” and the second half: “or maintain or prevent deterioration of a chronic condition.”
The first portion of this definition describes preventive or wellness care. The second portion describes what is often called supportive care. Medicare intends doctors to realize that both definitions are still maintenance and, therefore, not covered.
The Guidelines for Chiropractic Quality Assurance and Practice Parameters, also known as the Mercy Guidelines, state that maintenance or preventive care is defined as appropriate professionally acceptable treatment, usually for a chronic condition or after completion of therapeutic or supportive care, directed at a symptomatically stationary condition with anticipation of maintaining optimal body function, and usually provided on some routine or regular basis.3
Continued treatment after a patient has reached maximum improvement, resolution, and/or stabilization of a condition would constitute maintenance-type care in nature. This type of treatment, by definition, is not covered by most third-party payers.
Supportive care is defined by the Mercy Guidelines as treatment or care for patients having reached maximum improvement, in which periodic trials of withdrawal from care fail to sustain previous therapeutic gains that would otherwise progressively deteriorate.
Supportive care follows appropriate application of active and passive care including lifestyle modification. It is appropriate when rehabilitative and/or functional restorative and alternative care options including home-based self care and lifestyle modifications have been considered and attempted.
Supportive care may be inappropriate when it interferes with other appropriate primary care, or when the risk of supportive care outweighs its benefits (e.g., doctor dependence, somatization, illness behavior, and secondary gain).
Regardless of the definition you follow, your choice to play in the third- party reimbursement sandbox requires that you understand what is appropriate to represent as “medically necessary” care on a 1500 billing form.
By virtue of putting that service on a bill, with your signature in box 31 you are indicating that you attest the
services are correct. Check out that line on your 1500 billing form right under the signature in Box 31. It says, “I certify that the statements on the reverse apply to this bill and are made a part thereof.” That means everything on the reverse side is applicable.
Now flip your 1500 billing form over and read the back. Most important is the paragraph that states, “I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations.”
Therefore, submitting billing to a third-party payer for maintenance or wellness care by way of a 1500 billing form engages the Federal False Claims Act. You don’t want to do that!
Avoid these traps
Be clear as to what active treatment is and what maintenance care is, and help your patients understand the difference.
Maintenance care is typically rendered on a regular basis to help maintain optimal body function, and usually when there is little or no active symptomatology or the symptoms have become dormant. It is often pre-scheduled, where the patient is being seen monthly, bi-weekly, etc.
Supportive care is typically rendered on an “as-needed” basis solely in response to exacerbations. Supportive care can be seen as “bursts of active care” rendered to return the patient to the previous stable status.
It can range from one to many bursts of care per year, depending on activities of daily living and other factors. These infrequent bursts of care may last from a few visits to several times a week for multiple weeks.
In order to delineate between the two, outside of Medicare, create a service code in your software for S8990. S8990 is literally defined as “physical or manipulative therapy performed for maintenance, rather than restoration.”4
Using this service code internally provides clarity that this service is not billable and therefore you do not expect it to be paid by a third-party payer. If a patient were to get a receipt and try to submit it on his or her own, or to a health savings account, your intentions would be clear.
Using diagnosis code V70.0, which is a routine general medical examination at a healthcare facility, further clarifies that you are not treating an active condition. It’s recommended that you never use this for Medicare patients. Billing maintenance care in Medicare has its own set of rules and regulations.
You are free to treat your patients as you see fit and according to your license. However, when you decide to bill a third party for that care, you must attest to its medical necessity. Wellness care, by definition, doesn’t meet that criterion.
Enjoy the benefits of these cash services when the patient is not in an active episode of care.
Help your patients understand that just because they have insurance, all care isn’t automatically covered. Wellness care is the destination to which all patients who embark on the chiropractic journey should strive to arrive.
Help them to understand the benefits of paying for care that keeps them healthy, happy, and on track like only chiropractic can.
1 Independence Blue Cross: Chiropractic Billing Guide. http://www.ibx.com/pdfs/providers/claims_and_billing/chiropractic_b illin/ibc_chiropractic_billing_guide.pdf.
2 Medicare: CMS Manual. http://www.cms.gov/Transmittals/downloads/ r23bp.pdf.
3 Mercy Guidelines. http://www.worldchiropracticalliance.org/positions/ mercy.htm.
4 HIPPASpace. http://www.hipaaspace.com/Medical_Billing/Coding/Healthcare.Common.Procedure. Coding.System/S8990.