In 2002, the Centers for Medicare and Medicaid Services (CMS) added the code, S8990, to its list of HCPCS National Level II codes. See, e.g., "HCPCS Temporary National Coding Decisions for 2003," Colorado Department of Human Services, pp. 9-11.

CMS currently defines "S8990" as "Physical or manipulative therapy performed for maintenance rather than restoration" (emphasis added). The short description of the code is "PT or manip for maint."

In order to determine whether treatment constitutes "maintenance care" for Medicare purposes, providers are encouraged to review the Medicare Carriers Manual (MCM). For example, when it comes to treatment by chiropractors, MCM Section 2251.3 defines manipulative treatment as "maintenance care" when the following applies:

Medicare Carriers Manual, Section 2251.3

In other words, when it comes to treatment by a chiropractor, the MCM states that once a patient's functional status has remained stable, and there is no more reasonable expectation of additional improvement in functionality, the care is maintenance in nature for Medicare purposes (i.e., "not medically necessary" according to Medicare) and providers can or should begin to bill the care using the S8990 code.

Important note – Just because Medicare defines maintenance care as treatment which is "without additional functional improvement," does not mean that all carriers or areas of law adopt the same definition. For example, it appears that many workers' compensation systems define "medically necessary" treatment as care which "cures or relieves the effects of the injury." Arguably, the "cure or relieve" standard also applies to auto liability, medpay, PIP, and other coverages associated with accident cases.

What constitutes "medically necessary" care in the private insurance context depends primarily on the language of the underlying insurance policy or health benefit plan.

It should be noted that S8990 is a "temporary" HCPCS code. Since its introduction in 2002, the code has yet to be upgraded to "permanent" status. Private insurance carriers are not currently required to recognize it under HIPAA regulations. Nevertheless, a number of state and federal agencies, as well as private insurance entities, have elected to formally recognize or require the S8990 "maintenance care" code. See, for example, "Military Health System Coding Guidance: Professional Services and Specialty Coding Guidelines," Section 6.3 (Chiropractic Services), v.1, adopted by the U.S. Department of Defense, effective April 1, 2005, at p. 6-19; "Payment Policies for Services Provided to Injured Workers and Victims of Crime," Washington Department of Labor and Industries, eff. July 1, 2005, at p. 187; CIGNA Healthcare Coverage Position, No. 0267, Rev. Dec. 15, 2005, at p. 7.

Obviously, when a provider submits claims to a carrier containing the S8990 code, few if any carriers will pay the fee associated with the code.

Nevertheless, for those providers who treat patients on a maintenance care basis, the S8990 code is significant for at least two main reasons. First, assuming that you are not required by law or by contract to bill non-covered services to the carrier, you should be able to automatically assign the S8990 code to "patient responsibility" in your billing software system. This will prevent the billing software system from unnecessarily submitting the maintenance care charge to the carrier.

Second, bear in mind that when it comes to adjustments / manipulations by chiropractors, the S8990 code by itself does not require the chiropractor to perform or document pre- and post-manipulation assessment (whether such assessments are required by operation of some other law is beyond the scope of this advisory). The existence of a uniquely different code, combined with a reduced level of decision-making and documentation, arguably justifies a reduction in fee for the service. Therefore, the S8990 code merits the assignment of its own fee based on the level of decision-making, documentation and extent of service.

Use of the S8990 code may raise a number of questions. For example, what if, when you perform the S8990 service, you actually exercise or employ the same level of decision-making, the same level of service, and the same level of documentation as in the case of the corresponding CPT or CMT code? What significance, if any, might this have on the amount you charge for the CPT or CMT code?

Suppose you provide treatment as part of a "Wellness Plan?" Does the label or name which you place on the course of treatment necessarily justify the use of the S8990 code?

Suppose a carrier denies your claims as "not medically necessary." Do such denials automatically mean that the provider can or should begin using the S8990 code?

Lastly, assume that in addition to an adjustment / manipulation, you also perform ancillary therapies, all of which you consider to be "maintenance care." Should you "bundle" the various services (normally separately reportable under CPT standards) under one S8990 code, or should you use separate maintenance care codes for "each" item?

This advisory is designed to serve as an introduction only to the use of the S8990 code. Providers are encouraged to direct their questions to their respective coding consultants.