Making sure the necessary elements of documentation are present for chiropractic medical necessity for Medicare
MEDICALLY NECESSARY CARE IS ANY CARE that a third-party payer is legally or contractually obligated to pay. If a third-party payer states that the care you billed does not fall under chiropractic medical necessity, then what they are actually saying is that they have found an excuse to not pay for it.
Medicare, as a publicly funded third-party payer, is legally obligated to publish all of their rules and regulations. Look at the first paragraph of the Medicare Benefits Policy Manual, chapter 15, section 240.1.3, to determine what Medicare is looking for to prove the medical necessity of care:
“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by X-ray or physical exam, as described above.”
The first sentence states: “The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment.” We can get a little more clarity by looking at the enabling law at section 1862 (a)(1)(a) of the Social Security Act, which states: “(a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services — (1)(A) which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,”
When we put all of this together, we find that the first requirement of proving chiropractic medical necessity is that the patient must have a significant health problem in the form of a neuromusculoskeletal condition that results from illness, injury or a malformed body member that necessitates treatment.
The adjustment relationship to the condition
The next requirement is that the adjustment given must have a direct relationship to the condition and provide an expectation of recovery or improvement of function.
The next sentence states: “The patient must have a subluxation of the spine as demonstrated by X-ray or physical exam, as described above.”
So, the questions that need to be answered in the documentation to prove the medical necessity of the care are:
- Does the patient have a significant health problem?
- Is the problem a musculoskeletal condition?
- Did the condition result from illness, injury or a malformed body member?
- Is the adjustment expected to help this condition?
- Did you prove the presence of a subluxation and, for Medicare was it either by the use of X-rays or the P.A.R.T. examination?
- Did the patient benefit from the adjustment?
If your documentation can answer all of these questions affirmatively then you have proven the medical necessity of the care provided according to Medicare regulations. The following is a Medical Necessity Algorithm for Chiropractic:
Documentation and claims denial
Now that we have established what is necessary to prove medical necessity for Medicare, how do we use this information? First of all, make sure your documentation can answer all of these questions affirmatively.
Second, realize that many times Medicare reviewers deny claims simply because an element of your documentation is not present. For example, the patient may not be able to tell you what makes their condition better or worse and the Medicare reviewer would deny the claim as not medically necessary because the documentation does not contain aggravating or relieving factors.
In a case such as this you need to appeal the denial. You should generate a cover letter that focuses on the fact that your documentation meets all of the six requirements for medical necessity as stated in the Medicare Benefits Policy Manual, chapter 15, section 240.1.3. You should then list each of the six elements that prove chiropractic medical necessity and quote the section of your documentation that addresses each particular question. We must hold Medicare and all third-party payers accountable to their own regulations.
Chiropractic medical necessity and how claims are received
Many times, we assume the reviewers are smarter than we are. This is not necessarily the case. Most reviewers are registered nurses and are not trained to make the decisions that doctors are trained to make. When we only provide completed forms and a list of diagnoses for review, we are forcing them to re-create our medical decision-making process. As such, our documentation needs to be more than just the completed forms and a list of diagnoses. That is nothing more than the raw data that we use to base our decisions on, and registered nurses are not trained to make those decisions.
We need to provide a thorough assessment detailing what information is important, why it is important and what actions we have taken because of that information. This provides them with a full picture of why we are providing the care we are providing.
You are the doctor
Also, always keep in mind that just because a third-party payer says the care is not medically necessary, does not mean it is not clinically indicated. You are the doctor, and the patient has come to you for help. You are the one who has sat face-to-face with the patient and examined them.
It is your legal, professional and ethical responsibility to treat that patient regardless of what a third-party payer thinks or who is paying for the care. Be the doctor.
RON SHORT, DC, MCS-P, CPC, CPCO, is a 1985 graduate of Palmer College of Chiropractic who presents seminars and webinars across the country on Medicare, compliance, coding and billing, and documentation. He has written five books and several articles on Medicare. He is available to speak at your group or association meeting or to assist you with reviews, audits or appeals. He can be contacted at firstname.lastname@example.org or at 217-653-5921. Portions of this article were excerpted from his new book, “Chiropractic Documentation,” available at store.innovihealth.com/products/chiropractic-documentation.
 Medicare Benefits Policy Manual, Chapter 15, Section 240.1.3