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Recent Changes in the Medicare Chiropractic LCD

Tuesday, August 15, 2017   (0 Comments)
Posted by: Brian Fewell
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By Lyle Coleman, DC

The Chiropractic LCD is our contractor’s (National Government Services) local rule book for Medicare. There are some recent changes that all DCs need to know about to stay compliant with regulations.

  1. There is a new requirement with documentation regarding risk of adjustment for patients with relative contraindications to manipulation. For clarity I quote the relevant portions. The current language is:

    B. Contraindications
    Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B)

    The following are relative contraindications to dynamic thrust:

    Articular hyper mobility and circumstances where the stability of the joint is uncertain; Severe demineralization of bone; Benign bone tumors (spine); Bleeding disorders and anticoagulant therapy; and

    Radiculopathy with progressive neurological signs. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B) Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following: Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;

    Acute fractures and dislocations or healed fractures and dislocations with signs of instability; An unstable os odontoideum; Malignancies that involve the vertebral column; Infection of bones or joints of the vertebral column;

    Signs and symptoms of myelopathy or cauda equina syndrome; For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and A significant major artery aneurysm near the proposed manipulation. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B)

    The new language is:

    Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor must discuss this risk with the patient and record this discussion in the chart.

  2. In the “Limitations” section of the LCD, the following paragraph has been revised from:

    The five extraspinal regions referred to are: head (including, temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen (CPT Assistant Nov 98:38). Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943).

    to:

    There are five spinal regions addressed by this LCD: cervical region (atlanto-occipital joint), thoracic region (costovertebral/costo-transverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region (ref. CPT® Professional Edition 2017 p. 672).

    Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943). The five extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen (CPT Assistant Nov 98:38).

  3. The following statement has been moved to the last paragraph in the “Limitations” section:

    The need for a prolonged course of treatment should be appropriate to the reported procedure code(s) and medical necessity must be documented clearly in the medical record.

  4. The language for P.A.R.T has been revised in the “Documentation: X-Ray/CT/MRI” section of the LCD and the following paragraph has been added:

    On receipt of a request for documentation, at a minimum, the practitioner must submit the Initial Visit’s (ref. CMS 1500 box 14) Treatment Plan, the Concluding/Discharge Visit and Subsequent Visits that demonstrate any change in the History, Physical Exam or Treatment Plan.

  5. The “Utilization” section has been revised to indicate that only one chiropractic manipulation service for a beneficiary can be reimbursed per day.

  6. The following statement has been removed:

    Prolonged or repeated courses of treatment are more subject to medical review and may indicate maintenance therapy. Documentation to support the medical necessity of repeated courses of treatment must be present in the patient’s plan of care.

    And replaced with:

    Prolonged or repeated courses of treatment are more likely to undergo medical review

  7. The following source has been added:

    American Chiropractic Association / Medicare Administrative Contractor Collaborative Outreach Forums on February 26, 2015, September 24, 2015 and March 16, 2017.



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