Urgent Medicare Bulletin: Service-Specific Prepayment Reviews of Chiropractic Services


Attention Services for Jurisdiction K Part B Chiropractic Providers in Connecticut and New York

National Government Services will be conducting service-specific prepayment reviews on CPT code 98940 in the Queens, NY area and CPT Code 98941 in CT and the upstate and downstate NY areas.

A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred as ADS letters. Please note that when medical records are requested for chiropractic services, it is necessary to submit all the specific documentation as notated in the ADS, which would include but is not limited to:
  • Services up to three (3) months prior to and including the date(s) of service in question
  • Advance Beneficiary Notice of Noncoverage
The primary focus of the audits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADSs asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims.

Providers can assist in this process by:
  • Reviewing all contractor publications and LCDs
  • Understanding Medicare coverage requirements
  • Ensuring office staff and billing vendors are familiar with claim filing requirements
  • Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines
  • Responding to request(s) for records in a timely manner (CMS requires that providers respond to an ADS within 30 days of the request)
  • Ensuring documentation is legible and demonstrates that the patient’s condition warrants the services being reported and billed
Reports show that from June 2013 through March 2014, the average error rate for CPT code 98941 was:
Connecticut - 81.0
Downstate, NY area - 81.1
Queens, NY area - 91.2
Upstate, NY area - 76.6


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