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.

QualChoice covers many spine X-rays taken by chiropractors in their offices.

1)    CPT codes 72081 – 72084 – Total Spine Exam are not covered for chiropractic treatment.

2)    CPT codes 72081 – 72084 and 72120 – Scoliosis Exams are covered only if performed at an imaging center or hospital and read by a radiologist.

3)    CPT codes 72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72100, 72110, 72114 – Regional Skeletal X-rays are considered medically necessary for:

a)    Any age, with any of the following:

i)            A known congenital anomaly of the spine and no study available within the prior 12 months.

ii)          A history of a malignancy, with unexplained new symptoms (please coordinate all radiology with the PCP and/or Oncologist).

iii)         A history of spondylolisthesis with no study within 18 months and/or new trauma.

iv)        Significant trauma (head injury, spine injury) including spinal antalgia with ambulation severely impaired (e.g.: torticollis, LBS acute IVD displacement with antalgia and visually distorted posture).

v)          Unexplained weight loss with orthopedic chief complaints.

vi)        Known osteoporosis. If the patient is at risk but undiagnosed, a referral to the patient’s primary care physician for assessment or bone density study may be indicated. Skeletal X-ray is not acceptable as a screening tool for osteoporosis.

vii)       A palpable abnormal mass

viii)      Substance abuse

ix)        Prolonged corticosteroid use

x)          Fever of unknown origin – If the patient is febrile without known cause, the patient should be referred to the PCP for evaluation before having any manipulative treatment considered.

xi)        Suspected physical abuse

xii)       Suspicion of an extremity or spinal fracture

xiii)      No response to treatment after two weeks of conservative care.

b)    Age over 50, with no X-rays within the past year and with any of:

i)            Radiating pain

ii)          Extremity numbness

iii)         Extremity motor weakness or asymmetrical deep tendon reflexes

c)     Age over 60 with symptoms and no X-rays within the past 18 months.

4)    Please remember that ionizing radiation has a cumulative effect on the human body.

a)    Chiropractors are required to keep a record of their patients’ exposure to all X-ray studies, including CT, dental X-ray and radiation therapy.

b)    For the safety of the patient, coordinate care with other providers and do not duplicate studies or perform unnecessary X-rays.

5)    For children aged 16 years and younger, X-rays are covered only if performed at an imaging center or hospital and read by a radiologist.

Codes Used In This BI:

Addendum:

Effective 01/01/17:  CPT code updates incorporated into policy.