Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 12/31/2003 Title: Chiropractic Care
Revision Date: 06/01/2018 Document: BI020:00
CPT Code(s): 97001-97006; 97010; 97012; 97014;97016; 97018; 97022; 97024; 97026; 97028; 97032-97036; 97039; 97110; 97112-97113; 97116; 97124; 97139-97140; 97150; 98925-98929; 98940-98943; 99201-99205; 99211-99215; S8948
Public Statement

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.


Medical Statement

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 two 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:
97001 PT Evaluation (code deleted 1/1/17)
97002 PT Re-evaluation (code deleted 1/1/17)
97003 OT Evaluation (code deleted 1/1/17)
97004 OT Re-evaluation (code deleted 1/1/17)
97005 Athletic Training Evaluation (code deleted 1/1/17)
97006 Athletic Training Re-evaluation (code deleted 1/1/17)
97010 Hot or Cold Packs Therapy
97012 Mechanical Traction Therapy
97014 Electric Stimulation Therapy
97016 Vasopneumatic Device Therapy
97018 Paraffin Bath Therapy
97022 Whirlpool Therapy
97024 Diathermy e.g. microwave
97026 Infrared Therapy
97028 Ultraviolet Therapy
97032 Electrical Stimulation
97033 Electric Current Therapy
97034 Contrast Bath Therapy
97035 Ultrasound Therapy
97036 Hydrotherapy
97039 PT Treatment
97110 Therapeutic Exercises
97112 Neuromuscular Re-education
97113 Aquatic Therapy/Exercises
97116 Gait Training Therapy
97124 Massage Therapy
97139 Physical Medicine Procedure
97140 Manual Therapy
97150 Therapeutic procedure(s), group (2 or more indiv)
97161 PT Evaluation, low complexity (new code 1/1/17)
97162 PT Evaluation, med complexity (new code 1/1/17)
97163 PT Evaluation, high complexity (new code 1/1/17)
97164 PT Re-Evaluation (new code 1/1/17)
97165 OT Evaluation, low complexity (new code 1/1/17)
97166 OT Evaluation, med complexity (new code 1/1/17)
97167 OT Evaluation, high complexity (new code 1/1/17)
97168 OT Re-Evaluation (new code 1/1/17)
97169 AT Evaluation, low complexity (new code 1/1/17)
97170 AT Evaluation, med complexity (new code 1/1/17)
97171 AT Evaluation, high complexity (new code 1/1/17)
97172 AT Re-Evaluation (new code 1/1/17)
98925 Osteopathic Manipulation
98926 Osteopathic Manipulation
98927 Osteopathic Manipulation
98928 Osteopathic Manipulation
98929 Osteopathic Manipulation
98940 Chiropractic Manipulation
98941 Chiropractic Manipulation
 


Reference

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.


Application to Products

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.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.