Background
In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service program reported a 54 percent error rate for chiropractic services. The majority of those errors were due to insufficient documentation/documentation errors. Year after year these error rates appear. CMS is providing an explanation of the AT modifier to assist providers with correctly documenting claims for chiropractic services provided to Medicare beneficiaries. The active treatment (AT) modifier defines the difference between active treatment and maintenance treatment. Effective October 1, 2004, the AT modifier is required under Medicare billing to receive reimbursement for Procedure codes 98940- 98941 , 98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active/ corrective treatment (acute and chronic care). The policy requires the following:
1. Every chiropractic claim for CPT 98940/98941/98942, with a date of service on or after October
1, 2004, should include the AT modifier if active/corrective treatment is being performed; and
2. The AT modifier should not be used if maintenance therapy is being performed. MACs deny chiropractic claims for CPT® 98940/98941/98942, with a date of service on or after October 1, 2004, that does not contain the AT modifier. The following categories help determine coverage of treatment. (See the Necessity for Treatment, Chapter 15, Section 240.1.3, of the Medicare Benefit Policy Manual (pages 226-227)).
1. Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury (identified by X-ray or physical examination).
the result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.
2. Chronic subluxation: A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. Both of the above scenarios are covered by CMS as long as there is active treatment which is well documented and improvement is expected.
Maintenance: 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. The AT modifier must not be placed on the claim when maintenance therapy has been provided.
Be aware that once the provider cannot determine there is any improvement, treatment becomes maintenance and is no longer covered by Medicare.
Key points
For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, MACs may deny if appropriate after medical review determines that the medical record does not support active/corrective treatment.
You must place the AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary.
Maintenance Therapy 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.
The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied.
You should consider providing the Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary. Chiropractors who give beneficiaries an ABN will place the modifier GA (or in rare instances modifier GZ) on the claim. The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The beneficiary can then make a reasonable and informed decision about receiving and paying for the service. If the beneficiary decides to receive the service, you must submit a claim to Medicare even though you expect that Medicare will deny the claim and that the beneficiary will pay.
"Since March 3, 2008 CMS has issued one form with the official title "Advance Beneficiary Notice of NonCoverage (ABN)" (form CMS-R-131). A properly executed ABN must use this form for each date an ABN is issued and all the required fields on the form must be completed including a mandatory field for cost estimates of the items/services at issue and a valid specific reason why the chiropractor believes Medicare payment for CMT will be denied on this date for this beneficiary. ABNs should not be issued routinely citing the same reason for each occurrence. One ABN cannot be used with added lines for future dates of services. For additional instructions on the proper completion of the ABN, see http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html on the CMS website.
Medicare Payments, Reimbursement, Billing Guidelines, Fees Schedules , Eligibility, Deductibles, Allowable, Procedure Codes , Phone Number, Denial, Address, Medicare Appeal, EOB, ICD, Appeal.
Medicare Guideline posts
- Home
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation process - how often provide need to do - FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list

Subscribe to:
Post Comments (Atom)
Top Medicare billing tips
-
CPT CODE and Description CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires thes...
-
Procedure code and description 11400- Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion d...
-
URIBEL- methenamine, sodium phosphate, monobasic, monohydrate, phenyls alicylate, methylene blue, and hyoscyamine sulfate capsule Uribel i...
-
LAPAROSCOPY ; LAPAROSCOPIC SURGERY Procedures and Related CPT and ICD-9 Procedure Codes CPT Code CPT Description ICD -9 ...
-
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
-
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
-
procedure code and description 11042 -Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square cm ...
-
Procedure code and description 93224 - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage;...
-
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
-
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 - Private insurance pay upt...

No comments:
Post a Comment