The following article was written in response to a question from a client that had received a denial from an insurance company because the care was “maintenance”. Both the chiropractor and patient were fighting the denial without much success. With Medicare now requiring an “-AT” modifier, this subject is even more important for our clients. Here is the response in full:
Dear Dr. Smith,
Thanks for the fax and the information on this patient’s appeal. Very frustrating for you both I’m sure. The patient makes some great points in her email in that without care she will probably end up needing surgery or ongoing prescriptions for pain medications (is that maintenance care?). Here is a very long answer to your simple question.
To some degree, the difference lies in the eye of the beholder. If a patient is coming in every several weeks or once per month and is not getting better, but is just using chiropractic adjustments to maintain her present level of function and pain level, then by definition she is on maintenance care. Medicare and most insurance companies do not cover that.
On the other hand, if a patient has a chronic condition and suffers occasional exacerbations of that condition due to work or activities of daily living, that are alleviated and improved by chiropractic adjustments, that would not be maintenance care.
While a paid chiropractic consultant may disagree, your documentation generally will have to clearly show the difference in order to get continued coverage.
How the insurance company’s computer processes your claim is the first obstacle. They have specific parameters built into the software to detect and reject maintenance care. This starts with your diagnosis. If you are doing prolonged treatment using only a subluxation diagnosis, this is one of the red flags for utilization review. (I suggest you read A Doctor’s Guide to Record Keeping, Utilization Management and Review, by Dr. Gregg Fisher. It can be ordered by phone at 570-368-2413 and we were told it was priced at $59). Your onset dates (reported in box 14 of the claim form) should also be updated as you treat new problems or new incidents. The diagnosis should be updated to reflect what the primary complaint is at the time.
Obviously, if you bill 30 visits over a year and one half, and the last ten visits are once per month, and your diagnosis, treatment and onset date do not change the entire time, it “obviously” looks like you are providing maintenance care.
Your SOAP note and documentation may help you at this point. Once the computer identifies that your care is “maintenance”, you will need to submit documentation to support medical necessity. It is not sufficient to mark “exacerbation” on the SOAP and assume that they will cover it. What was the exacerbation? Camping on the weekend, gardening, snow shoveling, lifting the grandkids, starting the lawn mower – patients tell you when they come in what happened. This needs to be documented under the subjective section of your notes.
Your documentation needs to be consistent. On 2/23/05 your SOAP indicates “new injury” and “exacerbation”. Was there a new diagnosis and onset date? Did you do a brief exam for the new injury? You and I know what you are doing, and so does the patient, but your documentation has to support the need for ongoing care.
Per Medicare’s requirements:
“F. Necessity for Treatment
“1. The 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. The patient must have a subluxation of the spine as demonstrated by xray or physical exam, as described above.
“Most spinal joint problems may be categorized as follows:
“*- 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 exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient's condition.
“*- 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), but where 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
“*2 - Maintenance Therapy
Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to 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. For information on how to indicate on a claim a treatment is or is not maintenance, see §240.1.3
“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.”
When you are billing Medicare with the “-AT” modifier, you are stating that the care was NOT maintenance. You will eventually get a routine random audit of your Medicare records and your documentation will have to support the level of care you provided.
Here is an excerpt from Dr. Gregg:
The following information is taken from A Doctor’s Guide to Record Keeping, Utilization Management and Review, by Dr. Gregg Fisher (Permission obtained.)
CHAPTER TWO -- MAXIMUM IMPROVEMENT / MAINTENANCE CARE / SUPPORTIVE CARE
The information in this chapter is very important in today’s third party payment system. Some insurance companies may have a provision in their policies for supportive care but not for maintenance care. This is the case in Pennsylvania’s Workers’ Compensation law.
It is important to know the different characteristics of both so that you can document your treatment accordingly. Have you been told your bill was being denied because your patient’s policy did not cover maintenance care? If not, you are definitely in the minority. This is sometimes a common denial tactic on the part of’ the insurance carrier. Reviewers are sometimes asked to give an opinion as to whether treatment is supportive care or considered maintenance care. This chapter will show you the differences in both of these terms to allow you to better document your treatment. This chapter will also help you understand maximum improvement and how you determine maximum improvement.
WHAT IS MAXIMUM IMPROVEMENT?
Maximum improvement (Mercy): A return to pre-injury status or a plateau point where the patient fails to improve beyond a certain level of symptomatology or disability. End point of’ care unless there is documented evidence of a permanent injury.
The important point in this definition is a return to a pre-injury status and the end point of care unless there is documented evidence of a permanent injury. This does not necessarily mean that the patient may not need further treatment, but this means that the patient has reached a plateau where no further regularly scheduled treatment would result in a clinical progression. Some insurance coverages are only responsible for treatment to the point of MMI/MCI, so the declaration of a patient at maximum improvement may have an influence on who pays future medical bills.
HOW DO YOU DETERMINE MAXIMUM IMPROVEMENT?
Determining maximum improvement is sometimes asked during a review, But how can one accurately determine MMI (Maximum Medical Improvement)/MCI (Maximum Chiropractic Improvement) based solely on a records review? The answer to that is very easy. It is sometimes difficult to determine maximum improvement based solely on a records review, but we will cover some areas to key in on:
1. You will first look at the subjective and objective findings and analyze them. The doctor should have done progress examinations at least monthly to evaluate the patient. Look at the examination findings and compare to the previous month’s examination findings to see if there continues to be significant improvement or the findings are remaining static. For subjective improvement look at the history but also any outcome assessment forms that were used.
2. Factor in a reasonable healing time estimate with any documented exacerbations and complicating factors.
3. Has the length of time between visits increased? Does a gap in treatment of two, three, or four weeks result in no clinical deterioration? In other words, if the patient does not get worse with two, three, or four weeks between visits, they may be reaching or are at maximum improvement. Remember, the doctor may have a sufficient rationale for monitoring the patient at a two, three, or four week interval. (Monitoring a home-based exercise program for example)
4. Did the patient have any pre-existing conditions? If so, is the patient at their pre-accident condition even though they might have continued symptomatology?
Knowing when a patient has reached maximum improvement is very important. As you will see, maximum improvement is a part of the definitions for both maintenance and supportive care. How could you be performing maintenance or supportive care if you have not first declared the patient at maximum medical improvement?
WHAT IS MAINTENANCE CARE?
Maintenance /Preventive Care (Mercy): Appropriate professionally acceptable treatment usually for a chronic condition or after completion of therapeutic or supportive care, directed at a symptomatically stationary condition with anticipation of maintaining optimal body function, and usually provided on some routine or regular basis. Continued treatment after a patient has reached MMI, resolution, and/or stabilization of a condition would constitute maintenance type care in nature.
WHAT IS SUPPORTIVE CARE?
Supportive care (Mercy): Treatment/care for patients having reached MMI, in whom periodic trials of withdrawal from care fail to sustain previous therapeutic gains that would otherwise progressively deteriorate. Supportive care follows appropriate application of active and passive care including lifestyle modifications, it is appropriate when rehabilitative and/or functional restorative and alternative care options including home-based self-care and lifestyle modifications have been considered and attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when the risk of supportive care outweighs its benefits, i.e., physician dependence, somatization, illness behavior, and secondary gain.
Supportive care (NCRS): Supportive treatment is to be considered the continuation of therapeutic treatment once the patient has reached a point of maximum improvement, while experiencing some permanent impairment. Supportive treatment is considered appropriate when there is documented failure of clinical trial of withdrawal, appropriate alternate forms of treatment including home-based self treatment have been considered and/or attempted, and the supportive treatment does not interfere with any other primary treatment that the patient may be receiving.
WHAT ARE THE KEY DIFFERENCES BETWEEN SUPPORTIVE CARE AND MAINTENANCE CARE?
There are a few key differences between maintenance care and supportive care that distinguish the two. Maintenance care is typically rendered on a regular basis to help maintain optimal body function and usually when there is little or no active symptomatology or the symptoms have become stationary. Supportive care is not typically rendered on a pre-scheduled or routine basis. Supportive care is usually rendered on an “as needed” basis solely in response to symptomatic exacerbations. This may vary from case to case. The patient may only require treatment for a few exacerbations per year but the treatment required to treat these exacerbations is at the frequency at three times a week for two weeks.
WHAT ARE THE CRITERIA FOR SUPPORTIVE CARE?
CRITERIA FOR SUPPORTIVE CARE
1. The patient must be at Maximum Medical Improvement.
2. Objective evidence of a permanent injury. Ancillary diagnostic tests must correlate with clinical examination findings due to the false positive rates with some diagnostic tests.
3. There must be documented trials of treatment withdrawal that resulted in deterioration of a patient’s condition. A trial of withdrawal is having the patient go a specified period of time without treatment and then reexamining the patient to see if there has been a deterioration of their clinical status. The doctor would examine the patient and the patient would go one month or more months before they are reexamined, No in-office treatment is rendered during this time. The examination findings are compared to see if there was an improvement or deterioration on the part of the patient. This procedure can again be repeated. Failure of the patient to maintain previous therapeutic improvement would qualify them for supportive care if the other criteria are met. You may also release a patient from care and they continue to return to receive palliative care for symptomatic exacerbations. If the patient meets the other criteria, then they would qualify for supportive care. A conditional release (to be covered later) may also be used to show a deterioration of time clinical status without treatment and help justify the need for continued care.
4. Alternative treatments must have been tried.
5. Care is typically rendered on a PRN (“as needed”) basis in response to an exacerbation. The visits should not be prescheduled.
6. Frequency typically should not exceed one or two times per month but this may vary depending on the specifics of the case.
7. Supportive care does not interfere with any other primary care.
Since the typical frequency is one to two times per month, I would not recommend having the patient schedule every other week. If a reviewer picks up on this (and I’m sure they will), they may deny treatment because it is “prescheduled” and would be considered more of a maintenance type of care. Remember, supportive care is rendered in response to symptomatic exacerbations and is not pre-scheduled.
Long-term supportive care is treatment to return the patient to pre-exacerbation status and improve or maintain activities of daily living and/or work status. Mental attitude may be improved and time patient’s reliance on medication is decreased. Supportive care may also be rendered as a preventative to surgery. The doctor must understand the psychosocial involvement in chronic pain and avoid physician dependence as much as possible by advocating active involvement on the part of the patient.
WHAT IS A CONDITIONAL RELEASE?
A conditional release is when the doctor releases a patient on the condition that the patient does not experience an exacerbation of symptoms in a specified period of time. Recurrences of musculoskeletal complaints are commonly seen in practice, if you permanently release a patient and they suffer a recurrence one week after you released them, it may be difficult to convince the insurance company that it is still the same injury. The doctor would release the patient and specify a time frame, usually not more than 60 days. If the patient does not have a recurrence, they will be considered permanently released. A new injury would certainly not qualify. The recurrence would be only due to the patient’s activities of’ daily living and not a new mechanism of injury. The typical treatment would be relatively minor to resolve the patient’s recurrence.
For example, Mr. Smith’s subjective and objective findings have improved. Today he will he given a conditional release. If he has a recurrence of symptoms in the next thirty days he is to call our office and return for care. If he does not require care within the thirty day period, we will consider him permanently released from treatment of his injuries sustained on 1/11/91.
Using a conditional release will be a benefit to both the doctor and patient. I am sure that most of us have treated a patient and released them from care only to have the patient return for a symptomatic exacerbation. If this happens in the Worker’s Compensation or auto insurance system, there is a likelihood that treatment beyond when the patient was released will be denied by a peer reviewer. This scenario can be avoided by using a conditional release.
There is still some confusion on terms here between maintenance and supportive care. Dr. Gregg refers to supportive care as covered. Some insurance companies will still not cover supportive care per the wording of their policy (as it appears in your case). However, it still goes back to you documentation and billing practices. If you can clean those up, I think you stand a chance of getting this approved.
So, where would I go from here? I think you have to add a report to your records stating why you feel this should have been covered and adding information that may have been omitted from your notes (do not obviously change your notes). You will have to add this note and address the note in your appeal.
Please review your documentation and claim forms from the above perspective.
Now, all that being said, and assuming you have read this far, nothing in the above should stop or prevent you from providing maintenance care to your patients. Maintenance care is the heart and soul of chiropractic and vital for your patients and practice well-being. The fact that it isn’t covered by insurance is a fact of life. Come up with a maintenance plan for your patients so that they can pay cash or can purchase a wellness package. You don’t have to bill insurance or you can bill using the CPT code 99401. Usually this is denied, but it may help the patient with their deductible and may even be covered. Here is an example of one clinic’s policy on wellness care:
“The clinic will provide whatever services the doctor determines that you will need each visit (CPT code 99401 Risk factor reduction intervention provided to a healthy individual). This may include chiropractic adjustments, therapy and consultation.
“The fee for wellness care is $25.00 per visit and must be paid at the time of service. We accept cash, checks, Visa and Mastercard. We will not bill your insurance for this service, as wellness care is not considered a benefit of health insurance.
“If you develop a new condition, or are injured, or are in an accident. the doctor will decide if you can remain on the Wellness care program or if your case can now be billed to your health, worker’s comp, or auto insurance.”
Per the 2005 CPT code book, the 99401 code is used for: “Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes”.
I know for me personally, I’ve been adjusted for over twenty years. I usually get adjusted once every week or two. Often, it is for exacerbations of chronic conditions (driving many miles, sleeping in hotels, etc). Sometimes it is simply for maintenance (wellness) and prevention. Other times, like recently or when I first sought chiropractic care, it is for an acute condition or injury. I would guess 75% of the care I have received has been for conditions that insurance would cover, but it all goes back to how it is billed and how the documentation reads.
I hope this answers your questions.