Coverage for chiropractic services extends only to treatment by means of manual manipulation of the spine to correct a subluxation.  All other services furnished or ordered by chiropractors are not covered.

Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.

Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands.

• Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, for the device itself.
• No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered under §1861(s)(3) of the Act if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy. 
• An x-ray is not required to demonstrate the subluxation.  However, an x-ray may be used for this purpose if the chiropractor so chooses.

The patient must have a significant health problem in the form of a neuro-musculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam, as described above.

Most spinal joint problems fall into the following categories:

• Acute subluxation - A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.
• Chronic subluxation - A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

A chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, services may be denied if appropriate after medical review.

The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.  The designation is made in relation to the part of the spine in which the subluxation occurred.

Area of Spine	Names of Vertebrae	Number of Vertebrae	Short Form or Other Name
Neck	Occiput	7	Occ, CO
	Cervical		C1 thru C7
	Atlas		C1
	Axis		C2
Back	Dorsal or	12	D1 thru D12
	Thoracic		T1 thru T12
	Costovertebral		R1 thru R12
	Costotransverse		R1 thru R12
Low Back	Lumbar	5	L1 thru L5
Pelvis	IIii, r and 1		I, Si
Sacral	Sacrum, Coccyx		S, SC

 

 

 

 

 

 

 

 

 

In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment.

There are two ways in which the level of the subluxation may be specified.

• The exact bones may be listed, for example: C5, C6, etc.
• The area may suffice if it implies only certain bones such as: Occipito-atlantal (occiput and C1 (atlas)), lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).

Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:

• Off-centered
• Misalignment
• Malpositioning
• Spacing - abnormal, altered, decreased, increase
• Incomplete dislocation
• Rotation
• Listhesis - antero, postero, retro, lateral, spondylo
• Motion - limited, lost, restricted, flexion, extension, hyper mobility, hypomotility, aberrant

Other terms may be used. If they are understood clearly to refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.

A subluxation may be demonstrated by an x-ray or by physical examination, as described below.

1. Demonstrated by X-Ray - An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.
   
   
2. Demonstrated by Physical Examination - Evaluation of musculoskeletal/nervous system to identify:
   • Pain/tenderness evaluated in terms of location, quality, and intensity;
   • Asymmetry/misalignment identified on a sectional or segmental level;
   • Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and,
   • Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.

   To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under “physical examination” are required, one of which must be asymmetry/misalignment or range of motion abnormality.

   The history recorded in the patient record should include the following:

   • Symptoms causing patient to seek treatment;
   • Family history if relevant;
   • Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
   • Mechanism of trauma;
   • Quality and character of symptoms/problem;
   • Onset, duration, intensity, frequency, location and radiation of symptoms
   • Aggravating or relieving factors; and,
   • Prior interventions, treatments, medications, secondary complaints.

Contraindications
Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. The following are relative contraindications to dynamic thrust:

• Articular hyper mobility and circumstances where the stability of the joint is uncertain;
• Severe demineralization of bone;
• Benign bone tumors (spine);
• Bleeding disorders and anticoagulant therapy; and,
• Radiculopathy with progressive neurological signs.

Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:

• Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
• Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
• An unstable os odontoideum;
• Malignancies that involve the vertebral column;
• Infection of bones or joints of the vertebral column;
• Signs and symptoms of myelopathy or cauda equina syndrome;
• For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and,
• A significant major artery aneurysm near the proposed manipulation

Reasons for Noncoverage

The following services are not covered.  A provider can bill the member for the denied service.

• Coverage for chiropractic services extend only to treatment by means of manual manipulation of the spine to correct a subluxation.  All other services furnished or ordered by chiropractors are not covered. 
  
• Extraspinal manipulation, code 98943, are not covered.
  
• Services performed for conditions other than those indicated in the diagnosis code section of this policy are not covered.
  
• Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Services without the AT modifier will be considered maintenance therapy and denied.

Documentation Requirements

The word “correction” may be used in lieu of “treatment.” Also, a number of different terms composed of the following words may be used to describe manual manipulation as defined above:

• Spine or spinal adjustment by manual means;
• Spine or spinal manipulation;
• Manual adjustment; and,
• Vertebral manipulation or adjustment.

Initial Visit - The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. History as stated above.
   
   
2. Description of the present illness including:
   • Mechanism of trauma;
   • Quality and character of symptoms/problem;
   • Onset, duration, intensity, frequency, location, and radiation of symptoms;
   • Aggravating or relieving factors;
   • Prior interventions, treatments, medications, secondary complaints; and,
   • Symptoms causing patient to seek treatment.
     
     

     These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

3. Evaluation of musculoskeletal/nervous system through physical examination.
   
   
4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.
   
   
5. Treatment Plan: The treatment plan should include the following:
   • Recommended level of care (duration and frequency of visits); 
   • Specific treatment goals; and
   • Objective measures to evaluate treatment effectiveness.
     
     
6. Date of the initial treatment.

Subsequent Visits The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. History
   • Review of chief complaint;
   • Changes since last visit;
   • System review if relevant.
     
     
2. Physical exam
   • Exam of area of spine involved in diagnosis;
   • Assessment of change in patient condition since last visit;
   • Evaluation of treatment effectiveness.
     
     
3. Documentation of treatment given on day of visit.

Append the AT modifier when providing active/corrective treatment to treat acute or chronic subluxation.

Special Bulletin

02/08/10, Correct Reporting of Spinal Manipulation Services 

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-Line Pub. 100-02, Chapter 15, Sections 30.5, 240 – 240.1.4

West Virginia Palmetto GBA Assigned ICD-9 Codes for National Coverage Determination & Coverage Provisions in Interpretive Manuals.