Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Some chiropractic services may be subject to prepayment review.

2)    For chiropractic coverage and limits, consult the member’s coverage document.

3)    See BI220 for guidance regarding chiropractic x-rays.

4)    Maintenance therapy is not covered.

5)    Chiropractic services are normally considered rehabilitative in nature (to restore a loss of function).  Chiropractic services for habilitative purposes (for congenital disabilities or developmental delays) are only covered by certain plans—see your coverage documents and BI398.

1)    Evaluation and Management Charge:

a)    May occur once per 90 days or to re-evaluate after 12 treatments. Outside of these circumstances another E&M code will only be allowed if there is a new injury/diagnosis. Includes the following components, if they are performed:

i)         History of present illness

ii)        Past medical/chiropractic history

iii)       Review of Systems

iv)       Family History

v)        Social History

vi)       Occupational History

vii)      Review of records from previous providers

viii)    Review of pain scales, or other questionnaires

ix)       Physical/manual examination

x)        Orthopedic and Neurologic examinations

xi)       Measurements of circumferences, lengths or range of motion of body parts – whether by hand or instrument (exceptions will be noted)

xii)      Interpretation of lab work or x-rays done at another facility

xiii)    Recording/reporting of findings

xiv)    Instruction of the patient regarding exercise, ADLs, nutrition, home care or any other subject

xv)     Case management

xvi)    Outcome assessment

2)    Manual Treatment:

a)    Chiropractic treatment is intended to be for acute problems and be of short duration.

b)    Chiropractic Manipulative Therapy (CMT) charges will be handled as follows:

i)     98940 – 1-2 spinal regions – allowed routinely

ii)    98941 – 3-4 spinal regions – allowed routinely

iii)   98942 – 5 or more spinal regions – we expect this charge to be rarely used and it will only pay if there are 5 corresponding diagnoses. 

iv)   98943 – Extra spinal – may be used alone or in conjunction with 98940-98941

c)    Soft Tissue Treatment codes:

i)     97124 – Massage therapy is not covered

ii)    97139 – “Other” therapy technique is included in the CMT codes 98940-98941

iii)   97140 – Manual therapy techniques (mobilization) techniques (mobilization) is payable in a region other than the area that is manipulated—a 59 modifier is required to denote a separate and distinct region.

d)    Other soft tissue treatment codes may be subject to prepayment review and will be allowed only once per course of treatment, including:

i)     97113 – Aquatic therapy

ii)    97116 – Gait training

e)    Osteopathic Manipulative Treatment (OMT) codes should not be billed by a Chiropractor:

i)     98925

ii)    98926

iii)   98927

iv)   98928

v)    98929

f)     Acupuncture is not covered under this plan.

g)    Physical Therapy, Occupational Therapy and Speech Therapy evaluation and re-evaluation codes should not be billed by a Chiropractor:

i)     97161 – PT Evaluation, low complexity

ii)    97162 – PT Evaluation, med complexity

iii)   97163 – PT Evaluation, high complexity

iv)   97164 – PT Re-evaluation

v)    97165 – OT Evaluation, low complexity

vi)   97166 – OT Evaluation, med complexity

vii)  97167 – OT Evaluation, high complexity

viii)97168 – OT Re-evaluation

ix)   97169 – AT Evaluation, low complexity

x)    97170 – AT Evaluation, med complexity

xi)   97171 – AT Evaluation, high complexity

xii)  97172 – AT Re-evaluation

h)    Therapeutic exercise, 97110, and neuromuscular reeducation, 97112, will be covered up to three units combined per session.  Therapeutic exercise and neuromuscular reeducation must be appropriately documented according to Medicare standards, including the specific exercises participated in, the time for each exercise, and the total therapeutic time spent.  Remember that only exercise time during which the provider is physically working with the patient one-on-one is billable.

3)    Physical Medicine & Rehabilitation Modalities:

a)    Modalities are recognized as being an important adjunct to CMT or soft tissue techniques. Up to three of the following modalities will be paid per session:

i)     97012 - traction

ii)    97014 – electrical stimulation

iii)   97024 – diathermy

iv)   97032 – electrical stimulation, manual, constant attendance, 15 minutes

v)    97035 – ultrasound, constant attendance, 15 minutes

b)    Other modalities will not be allowed on the same day as CMT or OMT charges:

i)     97010 – hot or cold packs

ii)    97018 – paraffin bath

iii)   97022 – whirlpool

iv)   97026 – infrared

v)    97028 – ultraviolet

vi)   97033-97034, 97036, 97039 – modalities requiring constant attendance

c)    97016 – Vasopneumatic devices—see BI227.

4)    Laboratory Studies:

a)    Laboratory studies are not generally necessary for the diagnosis of conditions treated by chiropractic.

b)    When laboratory studies are required, they will be ordered through a participating independent laboratory, such as LabCorp or Quest. The patient should be sent to the nearest draw station, or the specimen may be delivered or sent to the participating independent laboratory.

5)    X-Rays:

a)    Most chiropractic evaluation and treatment can be accomplished without taking X-rays, or by utilizing films taken prior to the patient presenting to the chiropractor.

b)    When needed, X-rays will be permitted; see BI220.

6)    Visit Limitations:

a)    The visit expectation is that 8 visits will be allowed with each episode of care.  Visits beyond 8 may be subject to pre-payment or post-payment review for documentation of medical necessity.

7)    Low Level Laser Therapy:

a)    Low level laser therapy has not been shown to be effective for any indication in peer reviewed studies.  This therapy is considered experimental and investigational and is not covered.

Codes Used In This BI:

Resource Document:

BI020 Chiropractic Care RD

EOC Statement:

Covered under physical therapy benefits and chiropractic benefits. Group therapy is listed as exclusion.

Addendum:

1.    Effective 01/01/2017: CPT code 97020 is no longer a valid code. Replaced with 97022 throughout BI. Updated BI to reflect new/deleted CPT codes. The following codes were deleted 1/1/17: 97001 – 97006. These codes were replaced with the following new codes effective 1/1/17: 97161 – 97172.

2.    Effective 12/01/2017: Modified limits on E & M codes and removed PA for 98942.

3.    Effective 3/12/2018: Clarified distinction between rehabilitative chiropractic services and habilitative chiropractic services.

4.    Deleted code 99201 from the code ranges (eff 01-01-2021).

5.    Effective 03/01/2022: Updated to note that up to 3 PMR modalities would be paid per session.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.