Denial Reason, Reason/Remark Code(s)
  • PR–170: Payment is denied when performed/billed by this type of provider
  • CPT codes: 97010 through 97799
  • HCPCS code: G0279-G0283; G0295 and G0329 
Resolution/Resources
Medicare coverage of services performed by chiropractors is limited to treatment by means of manual manipulation of the spine to correct a subluxation, provided such treatment is legal in the state where performed. All other services furnished or ordered by chiropractors are not covered.

If a chiropractor orders, takes or interprets an X-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the X-ray can be used for documentation. However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor.

In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are hand-held with the thrust of the force of the device being controlled manually. While such manual manipulation may be covered, there is no separate payment permitted for use of this device.

Services such as office visits (evaluation and management services), diagnostic studies, physical therapy and other services rendered by chiropractors are not required to be submitted for coverage consideration by the Medicare program. The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. If a Medicare beneficiary believes a service may be covered or requests a formal Medicare determination for consideration by a supplemental plan; however, the provider must submit a claim.
  • To submit a claim for a non-covered service by a chiropractor, use HCPCS modifier GY to indicate that the service is statutorily excluded from coverage
  • You may submit both covered and non-covered services on the same claim
Note: Therapy services provided by a chiropractor, although non-covered, 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
Notice of Exclusion from Medicare Benefits Information
If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
  • CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the 'old' notice of exclusion from Medicare benefits (NEMB) language. Use of the revised ABN is optional for services that are excluded from Medicare benefits. 
  • If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GY. Refer to the Palmetto GBA Modifier Lookup tool for information on HCPCS modifier GY.
References

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

Email JJ Part B

Contact a specific JJ Part B department


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