October 23, 2014 - Updated 01.12.16
Progressive Corrective Action (PCA) Review: Chiropractic Services
The J15 Part B Medical Review department performed Progressive Corrective Action (PCA) reviews on chiropractic services throughout the year. The findings of PCA reviews occurring over 2015 are as follows:
- The documentation provided did not support the Local Coverage Determination (LCD) and Internet-Only Manual (IOM) for Chiropractic Treatment:
- No treatment plan (or vague plans of care),
- No objective measures,
- No measurable goals,
- No documentation of treatment effectiveness
- The range of motion was missing from the exam.
- No documentation of subluxation or areas treated.
- No documentation was found to support manual treatment.
- Failure to provide medical records for the probe review.
- Maintenance Therapy - The documentation supported maintenance therapy.
- The history lacked documentation to support new or active disease process.
- Based on the history, it was difficult to determine where, or if there were breaks in treatment.
- Wrong CPT Code - Providers billed for a higher level service than the number of areas treated.
- Failure to provide medical records for the probe review.
For more information on Medicare guidelines, including documentation required to process a claim, please refer to:
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 240 and subsequent sections
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 220
- LCD L33982: Chiropractic Services
- CGS Chiropractic Services Fact sheet
- Entries in Medical Records: Amendments, Corrections and Addenda
- Signatures and Compliance: Practitioner Offices and Billing Services
Reminder:
- It is important to append HCPCS Modifier GA only when applicable
- Please be sure the Advance Beneficiary Notice of Non-Coverage (ABN) is completed appropriately.