The Four Step Formula for Billing CMT

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Chiropractic Manipulative Treatment (CMT) is the life blood of most chiropractic clinics, and Medicare (CMS) is the gold standard when it comes to rules and regulations.  If a provider is able to satisfy Medicare guidelines, odds are good that he/she can satisfy any third-party payer or auditor.  CMS only pays chiropractic physicians for Chiropractic Manipulative Treatment (CMT), but fortunately they have outlined all that a provider needs to know to make sure the service is reimbursable. 

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Step One: P.A.R.T.

It all starts with documenting the existence of a condition that would respond to CMT, or the chiropractic adjustment.  While most chiropractic physicians would agree that the condition should be a problem with the spine, CMS tells us that the primary diagnosis must be a spinal subluxation.  Fortunately, CMS has outlined a way to document that a subluxation exists.  The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).  Per MLN Matters Number SE1601, Medicare Coverage for Chiropractic Services – Medical Record Documentation Requirements for Initial and Subsequent Visits, it is laid out as follows:

• P – Pain/tenderness: The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest with a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation, provocation, and so forth. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, and so forth.
• A – Asymmetry/misalignment: Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following: observation (such as posture and heat analysis), static palpation for misalignment of vertebral segments, and/or diagnostic imaging.
• R – Range of motion abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, and/or other measurement(s).
• T -Tissue tone, texture, and temperature abnormality: Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following procedures: observation, palpation, use of instrumentation, and/or test of length and/or strength.

The guidelines go on to tell us that CMS only requires that two of these four elements be documented in the record, one of which must be Asymmetry or Range of Motion. 

This exam is refreshingly simple.  It is a fast and easy way to show that a patient has spinal segmental dysfunction.  And this condition is perhaps the best one to justify the need for CMT, or the chiropractic adjustment.  Therefore, consider documenting P.A.R.T. in every region that receives billable CMT, regardless of payer.  Records for patients with private insurance, worker’s compensation, personal injury, and cash can all easily meet this standard.  And all of these payers would have a hard time disagreeing with the record that clearly documents the segmental dysfunction this way, meeting the guidelines of Medicare.

Step Two: Diagnose

Once the objective findings support the existence of a problem that is known to respond to the chiropractic adjustment, the next step is to assign the right diagnosis code.  Medicare has told us that the treatment they will pay for must be intended to correct a subluxation and that this must be diagnosed.  Even though the word “subluxation” is not used with the codes found at M99.0- in the ICD-10 tabular list, they are the codes that CMS have identified for describing it. 

If the M99.0- segmental and somatic dysfunction codes are good enough for Medicare, they are likely sufficient for any payer or third party who is looking for a reason that someone was adjusted.  Make sure that every region that is adjusted has the appropriate M99.0- code, and that each of these regions has clearly documented P.A.R.T.  Medicare specifically requires that M99.0- be primary and that each region has a secondary diagnosis as well, but other payers may be more flexible on the secondary diagnosis requirement.

Step Three: CMT

Now that the objective findings show that there is spinal dysfunction, and the ICD-10 code is appropriately assigned, Chiropractic Manipulative Treatment (CMT) can easily be justified.  The records should show a clear link as follows:

P.A.R.T. àM99.0- à CMT

A simple self-audit might include a review of each record to make sure that all the links in this chain are easily identifiable.  The three spinal CMT codes vary, depending on the number of regions addressed.  1-2 regions for 98940, 3-4 regions for 98941, and 5 regions for 98942.  Therefore, if billing for 98941, an auditor would look for 3 or 4 regions, each with P.A.R.T., and 3 or 4 M99.0- diagnosis codes. 

This would work for 98943 extraspinal CMT as well.  The records can show that the area was examined, that there are at least two elements of P.A.R.T., and that a code like M99.06 Segmental and somatic dysfunction of lower extremity or M99.07 Segmental and somatic dysfunction of upper extremity is linked to the 98943. 

Step Four: Medical Necessity

Steps 1-3 are critical, but the bigger picture must also be considered.  Even if all these other things are documented, medical necessity needs to be established.  This can be accomplished by adding a few more pieces to either end of the formula.  Before P.A.R.T., in the subjective part of the record, the patient should have identified a problem that he/she wants help with.  It is difficult to establish medical necessity if the provider treats areas that are not identified by the patient as part of the problem for which they came in..  For example, treating an asymptomatic knee, just because the provider decided to adjust it, would not be considered medically necessary.

At the other end of the formula, each procedure delivered must have a purpose or rationale.  For example, if limited range of motion was found in the exam, and increased range of motion is expected as a result of the chiropractic manipulation, then that can be documented to explain why the service is necessary.  And, in the bigger picture, the whole episode of care can be rationalized with documented functional loss, and goals focused on functional gains that are a direct result of the service rendered.  Ongoing progress is critical to supporting medical necessity, but that is another discussion for another time. 

If these four steps are used, a chiropractic physician can clearly and easily support CMT services in such a way that any third party payer or auditor should be satisfied that it was necessary and billed appropriately.