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 CPT® codes 98940-98942. 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.
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 CPT® codes 98940-98942. 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.