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De-Mystifying Active vs. Maintenance Care with Medicare

Medicare
Dr. Grant Shapiro
in Medicare
By Grant Shapiro DC MCS-P CPC-A

De-Mystifying Active vs. Maintenance Care with Medicare

Explaining the distinction between these two types of care feels like a scene from the movie Ground Hog Day. We wish we had a dollar for every time that we have been asked to clarify this topic. It’s possibly one of the least understood, yet the concepts are clear, based on the definitions provided. Read on for our clarified explanations.

Medical Necessity for Chiropractic care

Let’s start with a clear and precise definition of Medical Necessity for Chiropractic care according to Medicare.

The Medicare patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

What the Definition Says

What the Definition Means

The Medicare patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment

 

We know there must be an identifiable subluxation that can be corrected by manual means. However, this also implies there is a secondary neuromusculoskeletal condition that is the manifestation of the subluxation and translates to a loss of function, not just pain. Both the subluxation and the secondary neuromusculoskeletal condition should be included in the diagnosis and coupled together for each spinal region to be treated.

 

The manipulative services rendered must have a direct therapeutic relationship to the patient’s condition

 

The patient’s complaint(s) should be easily discernible in the initial visit history. The examination findings should quantify each complaint with solid PART findings for each spinal region to be treated. This connects the complaint and finding to the treatment rendered. Regional spinal manipulation should be easily connected to the regional findings.

 

And provide reasonable expectation of recovery or improvement of function

 

For medical necessity to be demonstrated, and therefore the visit to be deemed active treatment, the treatment must be corrective rather than supportive. Tracking symptoms and function on a visit-by-visit basis allows the provider to continuously show whether an expectation of recovery or improved function is still possible. When it is not, the patient must be graduated into maintenance care, for which Medicare expects them to pay.

 

When the services rendered to a Medicare patient fall into the definition described above and are reflected in your documentation, your service is most likely going to meet Medicare’s definition of Medical Necessary. In turn, the application of the AT modifier indicating Active Treatment is appropriate. Anything that falls outside of this definition is usually considered to be Preventive Maintenance or Wellness Care.

There is more to it than just simply meeting medical necessity. Medicare has documentation requirements as well as definitions to be aware of. Watch for Part 2 of this blog series where we’ll go into the details of these rules and why the PART process can be your best friend.

Read Part 2: Medicare Gives You the Rules: Just Follow Them


Dr. Shapiro has been a practicing Chiropractic physician since 1997, he graduated from Northwestern College of Chiropractic (now NWHSU). He is licensed to practice in both the US and Canada. He has owned and operated his own Chiropractic office for over 20 years.  He is a certified Compliance Specialist, MSC-P with Chiropractic proficiency, and a certified professional coder (CPC-Apprentice). In addition, he is an approved compliance monitor for the AZ state Board of Chiropractic Examiners.  He has a passion for teaching others and continual personal learning, expressed as a post-graduate instructor for University of Bridgeport College of Chiropractic, and now as part of the TEAM KMC University!

 

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