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Part B Medicare Coverage of Chiropractic Services
- Comprehensive Error Rate Testing
- Introduction to Chiropractic Services
- Chiropractic Coverage
- Maintenance Care for Chiropractic Services
- Medical Review Audits
- Modifiers
- Advance Beneficiary Notice of Noncoverage Liability
- Chiropractic Resources
- Proper Billing for Acupuncture
- Comprehensive Error Rate Testing Program
- Related Articles
Medicare Coverage of Chiropractic Services
Modifiers
AT Modifier
Used to indicate that the covered services billed are for active corrective treatment and the provider’s documentation supports medical necessity and Medicare coverage guidelines. For chiropractic services, the AT modifier would be appended to the spinal manipulation CPT codes 98940–98942 when active treatment is being performed, and the documentation supports medical necessity and coverage requirements. If CPT codes 98940–98942 are billed without a modifier the claim will be denied by the system as not medically necessary.
GA, GX, GY and GZ Modifiers
These can be used by physicians, practitioners, or suppliers to indicate services that are expected to be denied because of lack of medical necessity or statutory exclusion, and those that do not meet the definition of any Medicare benefit. The modifier GX was created to report on a claim when a provider has issued an ABN voluntarily for noncovered services.
Below are the definitions of each modifier and their appropriate applications.
GA Modifier: Redefined as “Waiver of liability statement issued as required by payer policy.” Used to report when a mandatory ABN was issued to a beneficiary for a covered service that is not likely to be covered by Medicare due to medical necessity. This modifier is frequently used by chiropractors to indicate that spinal manipulation is being provided as maintenance care. Medicare does not reimburse for spinal manipulation that is performed as maintenance care or does not meet for medical necessity.
GX Modifier: “Notice of liability issued, voluntary under payer policy.” Used to report when a voluntary ABN was issued for a service. The GX modifier would be appended in addition to the GY modifier.
GY Modifier: “Notice of liability not issued, not required under payer policy.” Should be used on all services that are statutorily excluded or do not meet the definition of any Medicare benefit. Providers do not have to submit claims for noncovered services (e.g., massage, therapy, X-ray, etc.) unless the beneficiary requests claims are submitted, or if a denial is needed for secondary insurance claims processing. Providers may voluntarily use an ABN form to advise beneficiaries of services that Medicare does not cover under any circumstances.
GZ Modifier: “Item or Service Expected to Be Denied as Not Reasonable and Necessary.” Used when a provider does not expect a service to be covered by Medicare, and does not have a valid ABN on file. Beneficiaries are not liable for payment of services, when they were not notified prior to the services being rendered that the service would not be covered by Medicare due to medical necessity.
Routine or blanket ABNs are usually not permitted. An ABN should only be given to a Medicare beneficiary when the provider has reason to expect that Medicare will deny payment for some or all of the services. That reason should be listed on the ABN.
Therapy services provided by a chiropractor, although noncovered, must be submitted according to therapy guidelines. Therefore, please be sure to include one of the therapy modifiers defined below. Therapy services submitted without the appropriate modifier will be rejected as unprocessable.
- HCPCS Modifier GN: Services delivered under an outpatient speech-language pathology plan of care.
- HCPCS Modifier GO: Services delivered under an outpatient occupational therapy plan of care.
- HCPCS Modifier GP: Services delivered under an outpatient physical therapy plan of care.
Reviewed 9/11/2024