Chiropractic maintenance care: How to recognize it, document it and code it

We tend to have our own dialect in this chiropractic profession. Maintenance care, wellness care, preventive care, active care, supportive care and the list goes on.

If you eavesdrop on a discussion between any four doctors of chiropractic, you will likely hear at least four different opinions on what these words mean. If you can’t recognize true maintenance care, you’re at risk of violating the policy of certain third-party payers who have very distinct definitions of this care. This article describes what maintenance care is and how it should be documented and coded in your practice. 

By definition

Maintenance or preventive care is defined as appropriate, professionally acceptable treatment, usually for a chronic condition or after completion of therapeutic active treatment. This care is used to treat a symptomatically stationary condition with anticipation of maintaining optimal body function on some routine or regular basis. Continued treatment after a patient has reached maximum therapeutic improvement, resolution and/or stabilization of a condition would constitute maintenance-type care in nature. This type of care is further defined by the Medicare program 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.” 

We know maintenance care is not typically considered medically necessary to third-party payers. For this reason, it’s recommended the patient is educated on the difference between these types of care early in the process or along the way. The expectation of most patients is that if the insurance policy says they get 20 visits per calendar year, they want their 20 visits, no matter what. In fact, they are almost always tied to a further clarification that this care must be medically necessary according to the definition of the medical review policy, and the physician in charge of the care must delineate which is which. Maintenance care should not be billed to insurance with the expectation of it being paid. Have you ever read the back of a CMS 1500 claim form? Certification and agreement to the language on the back of the 1500 billing form occurs when you affix your name and signature to box 31. Part of this attests to the fact that you believe the service is medically necessary and billable, not maintenance care. 

Patients who are discharged from active treatment and following the definition of a maintenance care routine should cover the cost of that care themselves. If you send the bill on behalf of the patient as active treatment, you are saying you believe it meets those guidelines for payment. Don’t risk that, unless you feel certain you can qualify the care you’re rendering as active care.  

Proper documentation

Patients in the maintenance phase of care may not require as much or as detailed documentation as those on active care. Using a simple SOAP format is perfectly fine, but what you include or exclude is extremely important. Remember, even if you are not billing insurance, your state licensing board usually has guidelines for minimal documentation requirements within the scope of your practice. Check with your individual state board to determine what rules may be in place for minimum documentation, even on maintenance care. The following are some criteria for what should be included for a daily SOAP note of a maintenance visit. 

Subjective: Document the patient’s lack of or minimal complaints. There should be some “patient reports” section of your note outlining what he or she is telling you. Remember, we all have aches and pains, but a significant neuromusculoskeletal problem is something quite different than “my neck is stiff or sore.” Some indication of a stable condition also supports that this is a maintenance visit.  

Objective: Report subluxations, restrictions in range of motion, notable spasm, etc. If you prefer to perform some orthopedic or neurological test, list the findings here. The extent to which you report these findings will most likely be much less than a typical active care visit.  

Assessment: Your note for a maintenance visit will likely include an assessment that this is maintenance care. The diagnosis may be as simple as subluxation or segmental dysfunction.  

Plan: If your treatment plan is for the patient to come monthly, indicate that. If you have a written maintenance care plan, indicate that you treated the patient according to the plan. As with all plans, you must indicate what treatment you rendered. If you manipulated, indicate the segments adjusted and any therapy performed. You can also indicate that the treatment was tolerated well. Be sure you sign the note.  

A maintenance visit SOAP note can be less specific because you are not saddled with proving the medical necessity of the visit. But make sure you don’t minimize the note to the point where you have crossed the line of minimal documentation requirements.  

Correct coding

Now that we know about documentation, let’s talk about the correct coding of maintenance care. When a patient is released to maintenance care the following are the correct billing codes:

• S8990 for all non-Medicare patients 
• 9894X with GA for Medicare patients once you have obtained the proper ABN 

Code S8990 is a Level II HCPCS code described by Centers for Medicare and Medicaid Services (CMS) as physical or manipulative therapy performed for maintenance rather than restoration. S8990 includes not only chiropractic adjustments, but also all services performed for maintenance rather than restoration. 

Private payers

While maintenance care often isn’t covered, if you must bill maintenance therapy to a private payer, code S8990 is usually the most appropriate code to use. Each payer is different, so you must check carrier contracts or contact the private payer directly to verify that the S8990 code is acceptable. 

Medicare

S8990 is not permitted for Medicare maintenance care under any circumstances. Practices must follow standard Medicare guidelines and report maintenance care using the appropriate CMT code (9894X) followed by the GA modifier to indicate the required ABN has been signed and is on file for this maintenance care procedure. 

Final thoughts

A clear understanding of the difference between active care, chronic care, supportive care and maintenance care will help you and your office team, so be sure to explain this to patients. Just because a patient is armed with a magic insurance card doesn’t mean all the care in your office is covered. Be sure to understand the definitions, the rules and the policy, and share that information early and often with your patients. When they understand what to expect in your treatment plan, and then blend that with the coverage they have, a smooth transition to wellness care can be expected. 

Understanding the proper documentation and coding of maintenance care in your office will help you sleep better at night knowing you are doing this correctly. 

REBECCA L. SCOTT, CPC, CPCO, CPB, began her chiropractic career more than 30 years ago. She has an associate’s degree in accounting and is a Licensed Clinical Chiropractic Assistant in the State of Maine. She’s a member of the Lewiston Chapter of the American Association of Professional Coders (AAPC) and is a certified specialist working in curriculum development and individual client consultant for KMC University. She began her chiropractic career as a file clerk and worked her way up to team leader. She specializes in accounts receivable and insurance billing. Chiropractic is her passion, and she loves being part of a profession that helps people have a better quality of life.