Medicare Audits for Chiropractors

National Government Services implemented a pre-edit audit that affects all chiropractors in New York and Connecticut effective 10/14/2010. This pre-audit causes notes to be requested for all claims submitted with CPT codes 98940 and 98941. We do not bill for all the chiropractors in New York and Ct, but the ones we do bill are are outraged.

Many of our chiropractors have a large Medicare patient load so this really affects their income. National Government Services states the reason for the pre-edit audit is due to previous audits done in both states indicating the codes were being billed improperly 11% of the time. Bottom line is that the 98940 is for 1 – 2 body regions, the 98941 covers the manipulation of 3 – 4 body regions and 98942 is for the manipulation of 5 or more body regions.

Medicare only pays for treatment of acute conditions therefore the notes and the diagnosis must reflect the number of regions you are billing for and it has to be an acute condition.

We completely understand that many chiropractors treat the whole spine and that most patients benefit from this treatment. Without the treatment many would become acute very quickly. However that type of treatment does not meet Medicare guidelines. Medicare will not pay for the treatment of a condition that will not improve or be corrected by the treatment. They also do not cover what they deem to be considered maintenance.

We had a humorous conversation with one of the customer service reps. We called for details on the pre-edit audits and we asked if this was on all claims for all chiropractors in New York and Ct. and were told “No not all claims – just the 98940s and 98941s.” We responded stating that there are only 3 codes reimbursable by Medicare. He replied “Really?” We also inquired as to how long the pre-edit audits would be in place. NGS informed us there is no set time frame for this audit. It could go on for a week, a month, or who knows.

In the meantime chiropractors will receive letters requesting notes for all claims received after 10/14/2010 for codes 98940 and 98941. The notes must be mailed with the letter to Medicare or the notes can be placed on a disk with a sheet attached to the disk with a list of all patient notes included. Our question is how long will it take for Medicare to handle this onslaught of notes and pay or deny the claims.

Currently we are only aware of this affecting N Y & Ct. chiropractors, however, who knows if other states will follow.


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