Inappropriate Medicare Payments for Chiropractic Services

摘要

As required by the Social Security Act, Medicare pays only for medically necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. Chiropractors must use the acute treatment (AT) modifier to identify services that are active/corrective treatment and must document services in accordance with the Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual (the Manual) when submitting claims. When further improvement cannot reasonably be expected from continuing care, the services are considered maintenance therapy, which is not medically necessary and therefore not payable under Medicare. We identified allowed claims with the AT modifier for beneficiaries with more than 12 claims from the same chiropractor in 2006. We then contracted with a medical review contractor to review medical records from a simple random sample of 188 claims. For each treatment episode, the medical records were reviewed to identify the initial visit and subsequent visits (if relevant) to determine whether each sampled claim was active/corrective treatment or maintenance therapy, the extent to which chiropractors supported their use of the AT modifier with proper documentation indicating active/corrective treatment, whether claims were coded properly, and whether documentation met the Manual requirements.