Medicare Part B - Notice of Maintenance Care

MEDICARE PART B - NOTICE OF MAINTENANCE CARE

Per Medicare Part B guideline, reimbursement for chiropractic treatment is permitted strictly for care that medical necessity has been clearly established for what Medicare has defined as Chronic or Acute subluxations. This notice pertains only to Medicare covered chiropractic service codes 98940, 98941 & 98942. Please see below for precise Medicare descriptions of covered and non-covered chiropractic treatment.

Maintenance Therapy Non-Covered Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable. Maintenance therapy isdefined as a treatment plan that seeks to prevent disease, promote health, and prolong andenhance the quality of life; or therapy that is performed to maintain or preventdeterioration of a chronic condition. When further clinical improvement cannotreasonably be expected from continuous ongoing care, and the chiropractic treatmentbecomes supportive rather than corrective in nature, the treatment is then consideredmaintenance therapy. Medicare Benefit Policy Manual, Chapter 15 - Transmittal 30.5 B

Necessity for Treatment Covered

The patient must have a significant health problem in the form of a neuromusculoskeletal

condition necessitating treatment, and the manipulative services rendered must have adirect therapeutic relationship to the patient’s condition and provide reasonableexpectation of recovery or improvement of function. The patient must have a subluxationof the spine as demonstrated by x-ray or physical exam, as described above.

• Acute subluxation-A patient’s condition is considered acute when the patient isbeing treated for a new injury, identified by x-ray or physical exam as specifiedabove. The result of chiropractic manipulation is expected to be an improvementin, or arrest of progression, of the patient’s condition.

• Chronic subluxation-A patient’s condition is considered chronic when it is notexpected to significantly improve or be resolved with further treatment (as is thecase with an acute condition), but where the continued therapy can be expected toresult in some functional improvement. Once the clinical status has remainedstable for a given condition, without expectation of additional objective clinical improvements, further manipulation treatment is considered maintenance therapy and is not covered. Medicare Benefit Policy Manual, Chapter 15 - Transmittal 240.1.3

I understand the information described above and acknowledge that my chiropractic care has reached Maintenance Therapy status. I understand that while my treatment status is deemed "maintenance" according to Medicare guideline, I will be responsible for payment of my chiropractic care. I have been given the opportunity to address any questions or concerns that I might have pertaining to the contents of this form and understand that I may at any time discuss my questions or concerns with the doctor or other office personnel.

______

Patient/Authorized Party SignatureDate

(Please Print) Patient Name ______

Form may be copied or customized by subscribers/customers for use in their own office – Not to be distributed