March 2019

March 2019

Maintenance Care and Third-Party Payers

“Can we bill maintenance care services to third-party payers?” That is a common question we hear from Chiropractors and their billing teams. The answer may vary depending on the payer. The rule of thumb - do not bill maintenance care to any third-party payer unless you have documented proof that it is a covered service for that payer.

Many of the policies that are part of the Affordable Health Care Act include habilitative coverage. It is important to confirm if this is inclusive of chiropractic services. Some policies will clearly state it does not pertain to chiropractic, while others are broader in their acceptance. Additionally, some union or self-funded plans may cover a specific number of visits in a calendar year, regardless of medical necessity.

If you come across a third-party payer who will consider reimbursement for maintenance charges, be careful to utilize appropriate diagnosis codes for maintenance care specifically, rather than active condition codes.

Most third-party payers have very distinct definitions of what they consider active vs maintenance care. As a Doctor of Chiropractic, it is best practice to become familiar with these definitions for each payer you submit claims to.

Billing and Coding Responsibly

We often find that providers attempt to find ways around these defined terms by utilizing different codes to describe the care, and then bill the payer for it. This is not acceptable. Please take a moment to read the following statement issued by the ACA on this topic:

“ACA often fields questions from doctors asking whether HCPCS code S8990 (“Physical or manipulative therapy performed for maintenance rather than restoration”) should be reported to Medicare for maintenance manipulation.  This code should not be reported.  S-codes, including S8990, were developed for use in the private sector only – they were never intended for use with Medicare.  Using non-standard Medicare coding could raise a red flag with your contractor.  When reporting maintenance chiropractic manipulative treatment to a CMS contractor (Medicare), use codes 98940-98943 without an AT modifier.”

While it may, at times, be appropriate to utilize S8990 with a private payer, or when creating your fee schedule, it is of utmost importance that you first clearly understand what maintenance care entails, and never bill this to a third-party payer unless, as stated previously, you have documented proof that it is a covered service.

Additionally, it is necessary to create an office policy regarding this and to utilize the appropriate CPT/HCPCS code to state this is for maintenance.  Use this, along with a wellness diagnosis, such as:

  • Z00.00 - Encounter for general adult medical examination without abnormal findings, Encounter for adult health check-up, NOS

  • Z41.8 - Encounter for other procedures for purposes other than remedying health state

  • Z51.89 – Encounter for other specified aftercare

Maintenance care is a vital component of what sets Chiropractic apart in the healthcare profession.  Let’s make sure we’re doing it right! Need an upgrade to your maintenance documentation? We have your answer with our minimum daily note form. Click here to check it out