What is the purpose of a comparative billing report on chiropractic manipulative treatment (CMT) of the spine?
CBR201614 was created to inform Medicare providers who submitted claims for CMT of the spine with a specialty of “35” about their billing and payment patterns. The CBR team reviewed Fee-for-Service (FFS) Medicare claims with dates of service from January 1, 2015 to December 31, 2015. For more information about CBRs, please visit our website at the link titled, Comparative Billing Reports.
Why was CMT of the spine chosen to be a topic for a CBR?
This topic was selected because CMT of the spine is an area that is vulnerable to fraud, waste, and abuse. According to a 2014 report by the Office of Inspector General (OIG), the improper payment rate for chiropractic services was 54.1 percent. More than 92 percent of these errors were due to insufficient documentation. To review the report for more details, see the following link: Medicare Fee-for-Service 2014 Improper Payments Report.
What is the specific focus of CBR201614?
CBR2016014 focuses on chiropractors whose billing and payment patterns are different from their peers. The metrics in the report include:
- Average allowed services per beneficiary by category
- Percentage of beneficiaries with over 24 visits in the year
- Percentage of CMT services billed with CPT® code 98942
To review an example of a mock provider’s CBR, see the following link: CBR201614 Sample CBR.
What Current Procedural Terminology (CPT®) codes were analyzed for this CBR?
The CPT® codes and their descriptions are listed below:
CMT spinal, 1-2 regions
CMT spinal, 3-4 regions
CMT spinal, 5 regions
Is receiving a CBR an indication that I’m billing incorrectly?
No. Receiving a CBR is not necessarily indicative of incorrect billing; however, it does mean that your billing is different from your peers. There can be many reasons your billing patterns may vary, including region, subspecialty, and patient acuity. If you still have questions and/or concerns after reviewing your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
Should a provider be concerned about an impending audit if they received a CBR?
The CBR team does not conduct audits nor have access to medical documentation needed to perform audits of claims. The purpose of CBRs is to inform providers about their billing and payment patterns. It may be beneficial, however, for providers to conduct self-audits. Resources that can help with setting up an audit process are located on our CBR website page at the link titled, Self-Audit Help.
Does the information in the CBR change the documentation and billing requirements established by the Medicare Administrative Contractors (MACs)?
No. The CBR is informational and does not alter, change, or negate any of the documentation and billing requirements established by the MACs. If you have questions about billing, please use the following CMS website link to access the contact information for your MAC: Review Contractor Directory – Interactive Map.
Where can providers find additional information regarding Medicare guidelines for chiropractic manipulative treatment?
The tables for the analyses in this CBR can be found at the web link titled, CBR201614 Statistical Debriefing.The links for the references and resources used in this CBR are located at CBR201614 Recommended Links.
Can a chiropractor opt out of Medicare?
No. Opting out of Medicare is not a choice for chiropractors. Per Chapter 15 of the Medicare Benefit Policy Manual, “The opt out law does not define ‘physician’ to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract.” For more information about opting out, see the following web link: Medicare Benefit Policy Manual, Chapter I5, Section 40.4.
Is it true that a provider can bill only 12 chiropractic visits per year for a Medicare beneficiary?
No. While there are no caps or limitations regarding the number of chiropractic care visits covered by Medicare, the service(s) must be reasonable and medically necessary. A study conducted by the Office of Inspector General (OIG) found that more than twelve (12) visits per year increases the likelihood that the services were not medically necessary. In fact, several of the MACs have screens that trigger reviews of documentation after a certain number of visits are reached and prior to allowing further care. The findings of the OIG report can be accessed at Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis, OEI 09-02-00530/June 2005.
Are there specific documentation requirements for CMT of the spine?
Yes. According to Novitas Solutions’ LCD L35424, “Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.” For additional documentation requirements on chiropractic services, select the following CMS web link: LCD L35424. In addition, the American Chiropractic Association (ACA) states in its guidelines, “Medicare’s documentation requirements are very specific, and it is possible to meet the requirements for documenting a subluxation within your daily chart notes.” The ACA advises that providers use a “common sense approach” when documenting their services in medical records and states that “appropriate documentation for one visit may not be adequate in another when other factors are taken into consideration such as frequency, duration of condition, severity of condition, past history, other documentation, etc.” To view the entire article, select the following web link: Commentary on Centers for Medicare and Medicaid Services (CMS)/PART: Clinical Documentation Guidelines.
What are objective measures related to the evaluation of treatment?
Objective measures are standardized ways of assessing a patient’s level of functioning and the effectiveness (or outcome) of treatment, while minimizing individual, subjective interpretation. Some examples that are useful in establishing objective measures with a baseline and goal include: pain scales, such as the Visual Analog Scale and/or the Verbal Response Scale; standing, measured in length of time; and range of motion (ROM), rated by degrees. Each objective measure and response to treatment must be addressed and documented at each visit. For a more detailed description of these objective measures, please select the following web link: Palmetto GBA, LLC FAQs.
If a provider adjusts three areas of the spine, is it correct to bill CPT® code 98941?
It depends which regions of the spine are adjusted. There are five regions of the spine: Cervical, Thoracic, Lumbar, Sacral, and Pelvic. When a provider adjusts three areas within one region of the spine, CPT® code 98940 should be billed; when the provider adjusts three to four regions of the spine, CPT® code 98941 is the appropriate code to bill. To receive payment from Medicare for spinal manipulation, documentation is required to support the number of regions treated and billed. The CPT® 2015 Professional Edition Manual containing information on proper coding can be accessed from the link titled, AMA Store.
Are hand-held devices that are utilized manually in treatment covered by Medicare?
No. According to Chapter 15 of the Medicare Benefit Policy Manual, “…manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.” More information regarding manual manipulation of the spine can be accessed at Medicare Benefit Policy Manual, Chapter I5 - Section 240.1.1.
Do non-par chiropractors have to bill Medicare for services provided to beneficiaries?
Yes. Non-par does not mean providers can bypass billing Medicare. Chiropractors can choose to be participating providers (par) or non-participating providers (non-par) in Medicare. MLN Matters® states in its publication: “A non-par provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.” For more details, see the following Medicare Learning Network® (MLN®) publications:
- Addressing Misinformation Regarding Chiropractic Services and Medicare, Number: SE0749/August 2012
- Misinformation on Chiropractic Services, ICN: 006953/March 2015
Do non-par providers have the same documentation requirements as par providers?
Yes. Regardless of whether a provider is a non-par provider or a par provider, Medicare has specific documentation requirements for chiropractic services. First and foremost, documentation must support that the services billed were rendered and that those services were medically reasonable and necessary. To view more about Medicare regulations, select the following web link: Misinformation on Chiropractic Services, ICN: 006953/March 2015.
Should providers have all patients sign Advanced Beneficiary Notices (ABNs) at the beginning of each year of treatment?
Issuance of an ABN is based upon the premise that a particular service is not medically reasonable and necessary and/or that Medicare may not pay for it. The Medicare Learning Network® (MLN®) publication titled, Medicare Advance Beneficiary Notices, states the following about providers issuing ABNs: “The ABN allows the beneficiary to make an informed decision about whether to get the item or service that may not be covered and accept financial responsibility if Medicare does not pay. If the beneficiary does not get written notice when it is required, he or she may not be held financially liable if Medicare denies payment, and you may be financially liable if Medicare does not pay.” Providers may issue single ABNs if they believe Medicare will not pay for extended treatment. ABNs are valid up to one year. More information on ABNs can be found at the following links:
How were claims’ data obtained for this report?
Claims with CPT® codes covered in this CBR, with dates of service from January 1, 2015 to December 31, 2015, were downloaded from the CMS Integrated Data Repository (IDR) and loaded into the Palmetto GBA, LLC Medicare Data Warehouse. Then, each provider’s data was compared to that of their peers (as identified by NPPES) located in their own state and the nation. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).
How were providers selected to receive CBRs?
The CBR data team analyzed claims with allowed services for the CPT® codes included in this CBR and identified those providers with different billing patterns when compared to their peers. Out of those claims, approximately 8,500 providers were selected to receive the reports. Providers who did not receive a CBR can view a mock report at the following link: CBR201614 Sample CBR.
Can you explain what Table 1 means?
Table 1 is titled Summary of Your Utilization and includes the CMT CPT® codes in this CBR. The table lists the CPT® code descriptions, as well as the allowed charges, allowed services, and beneficiary count for each code. To review an example of a mock provider’s report, follow the web link at CBR201614 Sample CBR.
What does Table 2 mean?
Table 2 compares a mock provider’s Average Allowed Services per Beneficiary to that of their peers. This table lists the provider’s average services per beneficiary, the state’s average services per beneficiary, a comparison with the state’s average, and national average services per beneficiary. The last column in the table is a comparison with the national percentage for the total services. To see Table 2 of the mock provider’s CBR, please select the web link titled, CBR201614 Sample CBR.
How are the peers defined?
Each billing provider was identified by National Provider Identifier (NPI). The peer groups that are used for comparison with individual providers were identified, as follows:
- State: All Medicare providers located in the provider's state, as identified by the National Plan and Provider Enumeration System (NPPES) File, with a specialty of Chiropractic (35) and with allowed charges for the Chiropractic CPT® codes 98940-98942
- National: All Medicare providers in the nation with a specialty of Chiropractic (35) with allowed charges for the Chiropractic CPT® codes 98940-98942
What do the comparison outcomes mean?
The four possible outcomes for the comparisons between the provider and peer groups are:
- Significantly Higher - provider’s value is higher than the peer value and the statistical test used confirms significance
- Higher – provider’s value is higher than the peer value, but either the statistical test does not confirm significance or there is insufficient data for comparison
- Does Not Exceed - provider’s value is not higher than the peer value
- N/A (Not Applicable) - provider does not have sufficient data for comparison
What’s the significance of Table 3?
Table 3 provides a comparison of the provider’s Percentage of Beneficiaries with Over 24 Visits in the Year to peers in their state and the nation. To illustrate this, refer to Table 3 of the mock provider’s CBR at the following link: CBR201614 Sample CBR. The results of the analysis in Table 3 illustrate that the provider Does Not Exceed the percentage for their state but is Higher than their national peer group, according to the results of the chi-square test. To view the results for each state and the nation, select the following link: CBR201614 Statistical Debriefing.
How should providers interpret Table 4?
Table 4 is titled Percentage of CMT Spinal Services Billed with CPT® Code 98942. For an illustration, refer to the mock provider’s CBR on our website link at CBR201614 Sample CBR. In this example, the provider has 72 percent for allowed CMT spinal services billed with CPT® code 98942, which is Significantly Higher than the state’s three percent. The mock provider’s percentage is also Significantly Higher than the national percentage of six percent. To review the results for each state and the nation, see the following link: CBR201614 Statistical Debriefing.