Revised 02/18/20

 

More and more plans are now covering wellness visits.  (Please see list below of some plans that DO cover wellness.)

 

It is very important when verifying benefits, to specifically ask of code S8990 is covered by the member’s plan.  (To ensure you get accurate information, do not ask if wellness/maintenance is covered; specifically ask if S8990 is covered!)

 

 

If Maintenance Care is Covered:

The AMA defines S8990 as "Physical or manipulative therapy performed for maintenance rather than restoration."

 

If maintenance/supportive care is covered by the member's plan, the service(s) must be accurately reported using HCPCS code S8990.  (Never use CMT codes if billing for maintenance/supportive care - even if the services are covered by the member's plan.)

 

Therapies and Manipulations:

As noted in the AMA definition for S8990, this code includes both therapies and manipulations, so providers should report S8990 when providing only a manipulation and/or when therapies are done in conjunction with the manipulation.

 

 

If Maintenance Care is NOT Covered:

If maintenance/supportive care is not covered by a member's health care plan, with few exceptions, it should not be billed to the payor. 

 

If a patient insists that you file a claim, do the following:

  1. Provide the patient with the HNS Maintenance/Supportive Care Letter to Patients, ask them to read it.
  2. Have the patient sign the HNS Maintenance/Supportive Care Waiver, and explain that while you are confident the insurance plan won’t cover it, you will be happy to file a claim provided they first agree, in writing, to pay for the service if the plan does not cover it.
  3. Then file the claim, accurately reporting the care as maintenance by using code, S8990.  The plan will deny the claim and the patient will receive an EOB showing the service is not covered.

 

If Maintenance Care is Covered by Secondary Payor

When maintenance care is not covered by the primary payor but is covered by the secondary payor, you must report S8990 to both the primary and secondary payor.  Billing the correct code (S8990) will result in a denial from the primary payor and an appropriate EOP denial to send to the secondary payor.

 

Additionally, a patient may need a receipt/super bill or EOP denial in order to seek reimbursement under a flexible spending account, HSA/HRA account.  Always ensure the receipt includes the S8990 code.

 

The ACA 

has published the following definitions:

 

"Preventive/Maintenance Care: 

Elective health care that is typically long-term, by definition not therapeutically necessary but is provided at preferably regular intervals to prevent disease, prolong life, promote health and enhance the quality of life.  This care may be provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent future problems.  This care may incorporate screening/evaluation procedures designed to identify developing risks or problems that may pertain to the patient's health status and give care/advice for these.  Preventive/maintenance care is provided to optimize a patient's health."

  

Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur.

 

"Supportive Care:

Long-term treatment/care for patients who have reached maximum therapeutic benefit, but who fail to sustain benefit and progressively deteriorate when there are periodic trials of treatment withdrawal. 

 

Supportive care follows appropriate application of active and passive care including rehabilitation and/or lifestyle modifications.  Supportive care is appropriate when alternative care options, including home-based self-care or referral, have been considered and/or attempted.  Supportive care may be inappropriate when it interferes with other appropriate primary care, or when risk of supportive care outweighs its benefit, i.e. physician/treatment dependence, somatization, illness behavior or secondary gain."

 

The AMA defines S8990 as "Physical or manipulative therapy performed for maintenance rather than restoration."

 

MMI - Important Note:

The clinical record must clearly indicate when maximum medical improvement (MMI) has been reached.  Once MMI has been reached, the patient should be released from care or switched to maintenance/supportive care.

 

HNS Payor Policies for Maintenance/Supportive Care

 

Absolute Total Care Members (Medicaid & Medicare - Allwell)

Maintenance and/or supportive care are not covered. 

 

BCBSNC Members

Maintenance and/or supportive care are not covered chiropractic benefits for the following members:

  • BCBSNC members
  • Blue Medicare Supplemental members
  • HSA/HRA members (high deductible plans)
  • ASO self-funded groups with the following exceptions:   

 

Exceptions:

Several groups for whom BCBS administers their plans DO cover maintenance. For those plans maintenance must be reported using S8990 

 
  • NC State Health Plan
  • The City of Cary
  • Piedmont Natural Gas
  • Waste Industries USA, Inc.
  • SAS Institute, Inc.
  • Wake Internal Med Consultants, Inc.

 Please note – this list is not all-inclusive so always verify benefits.

 

BCBS Out-of-State Plan Members

Benefits for BCBS out-of-state members are determined by the member's home plan.  Please contact the home plan directly to determine if maintenance and/or supportive care are covered.

If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member, but the treatment must be correctly reported using S8990.

 

CIGNA HealthCare Members

Maintenance and/or supportive care are not covered.

 

CIGNA Medicare Advantage Members

Maintenance and/or supportive care are not covered.

 

Federal Employee Plan Members

Benefits for FEP members are determined by the member's plan.  Please contact the FEP plan directly to determine if maintenance and/or supportive care are covered.

If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member, but it must be correctly reported using S8990.

 

Focus Plan Members

Maintenance and/or supportive care are not covered.

 

HealthTeam Advantage Members

Maintenance and/or supportive care are not covered.

 

Liberty Advantage Members

Maintenance and/or supportive care are not covered.

 

MedCost Members

Many MedCost payors cover maintenance and/or supportive care.  Please contact each payor to determine if maintenance and/or supportive care are covered for each of your MedCost patients.  If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member and this must be filed through HNS.  If maintenance care is covered, it must be reported using S8990.

 

PruittHealth Members

Maintenance and/or supportive care are not covered.

 

Select Health of South Carolina

Maintenance and/or supportive care are not covered.