Chiropractic medicine is a modality of treatment, which is based on the relationship between the structure and function of the human body. Services rendered are intended to support the spinal column and nervous system functions. Mountain State Blue Cross Blue Shield will provide coverage for Chiropractic Services when they are determined to be medically necessary when Plan approved medical criteria and guidelines have been met.

Manipulation/mobilization is a medical necessary service when performed with the expectation of restoring the patient’s level of function, which has been lost or reduced, by injury or illness. Manipulation/mobilization should be provided in accordance with an ongoing, written treatment plan. The treatment plan should include:

• Specific modalities/procedures to be used in treatment
• Diagnosis
• Degree of severity (mild, moderate, severe)
• Impairment characteristics
• Physical examination findings, x-ray or other pertinent findings
• Specific statements of long and short-term goals
• A reasonable estimate of when the goals will be reached (estimated duration of treatment)
• Frequency of treatment The treatment plan should be updated as the patient’s condition changes.

Payment may be made for up to 20 (unless contract limit is less) medically necessary outpatient manipulation/mobilization encounters per calendar year (January-December). If the chiropractic provider feels additional treatments are necessary beyond twenty (20) visits, then the provider must submit the information requested on the MSBCBS treatment plan form (copy enclosed) so that it may be reviewed by the utilization management department for medical necessity.

Procedures and modalities that are performed solely to relax and prepare the patient for             manipulation procedure {application of hot or cold packs (97010) and massage (97124)} are considered an inherent part of manipulation. These services are not eligible for separate payment when reported on the same day as manipulation.

Code 97140 (manual therapy techniques) is also considered an inherent part of a manipulation procedure and is not eligible for separate payment when reported on the same day as manipulation.

When codes 97010, 97124, and 97140 are performed on a separate body region, unrelated to the manipulation procedure, these procedures may be considered for separate payment. In these cases, modifier-59 should be reported with codes 97010, 97124, or 97140.

In addition to the treatment plan mentioned above, documentation may be requested to aid in making a determination of medical necessity for treatment, such as:

• Provider’s pertinent evaluation (exam findings)
• Progress notes
• Medical history, as it relates to manipulation/mobilization encounters
• Dates of aggravation or exacerbation of the condition/injury
• If patient has transferred their care from a different provider, then any medical information (as available) from the prior provider(s).

Chiropractic Services are not covered in any of the following circumstances:

• Maintenance program: A maintenance program consists of activities that preserve the member’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Manipulation performed repetitively to maintain a level of function is not eligible for reimbursement.
• Treatments for condition other than those related to neuromusculoskeletal conditions
• Diagnostic procedures/tests not within the routine scope of chiropractic, including: a. Laboratory test, except urinalysis b. X-rays other than spinal or appropriate extremity x-rays c. EMGs d. Injections
• The following therapeutic manipulations/modalities (when billed under a separate procedure code):
  • Physical therapy
  • Traction (axial or longitudinal)
  • Acupuncture
  • Application of hot and cold packs
  • Counseling (considered integral to the visit)
  • Mechanical or electric equipment used for manipulations or other treatment modalities (considered integral to a manipulation)
• Nutritional supplements
• Services beyond benefit plan visitation limitations or services that are excluded from the benefit plan
• Vertebral axial traction or decompression

The following treatments, procedures and/or diagnostic tests are covered when ordered within standard chiropractic care:

• Diagnostic Procedures:
  • Routine spinal x-rays (cervical, thoracic, lumbar-sacral) and appropriate extremity x-ray, CT, MRI
  • Patient interview
  • Physical examination
  • Urinalysis (with or without microscopic exam)
  • Muscle testing with report
  • Range of motion measurement with report
• Treatments
  • Spinal adjustment by manual means
  • Spinal manipulation utilizing techniques taught in an accredited chiropractic college
  • Manual adjustment or manipulation
  • Vertebral manipulation or adjustment
  • Major joint manipulation (shoulder, elbow, wrist, hip, knee and ankle)
  • Trigger point therapy or myofascial release
  • Only one manipulation/mobilization encounter will be eligible per day.

Medical necessity criteria - The chiropractor must justify medical necessity for continued chiropractic treatments and must be able to document the following:

• Continued improvement
• Improved range of motion (ROM) measurements but still impaired.
• Reduction in pain as per the pain scale (1 would be mild 10 would be severe)
• Improvement in ability to perform activities of daily living, (e.g. bathing, dressing, driving, etc.).
• Reasons that the recovery has extended beyond normal range.
• Patient has not reached long or short-term goals.

Therapy may be extended 1.5-2x due to prior episode, exacerbation, duration of onset prior to receiving treatment, arthritides, congenital abnormalities.

Manipulation (98925-98929, 98940-98943) includes a pre-manipulation assessment. This means that a separate evaluation and management (E/M) service should only be paid in the following circumstances:

1. Initial examination of a new patient or condition;
2. Acute exacerbation of symptoms or a significant change in the patient's condition; or
3. Distinctly different indications, which are separately identifiable and unrelated to the manipulation.

Physical medicine procedures and modalities that are performed solely to relax and prepare the patient for manipulation procedure {application of hot or cold packs (97010) and massage (97124)} are considered an inherent part of manipulation. These services are not eligible for separate payment when reported on the same day as manipulation.

Code 97140 (manual therapy techniques) is also considered an inherent part of a manipulation procedure and is not eligible for separate payment when reported on the same day as manipulation.

When codes 97010, 97124, and 97140 are performed on a separate body region, unrelated to the manipulation procedure, these procedures may be considered for separate payment. In these cases, modifier-59 should be reported with codes 97010, 97124, or 97140.

When a benefit, manipulation for all body regions should be paid in accordance with the following guidelines:

1. Manipulation is a covered service when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness. Manipulation should be provided in accordance with an ongoing, written treatment plan. The treatment plan should include:
   • The specific modalities/procedures to be used in treatment;
   • Diagnosis;
   • Degree of severity (mild, moderate, severe);
   • Impairment characteristics;
   • Physical examination findings - X-ray or other pertinent findings;
   • Specific statements of long and short-term goals;
   • A reasonable estimate of when the goals will be reached (estimated duration of treatment, e.g., number of weeks);
   • The frequency of treatment (e.g., number of times per week); and,
   • Equipment and/or techniques utilized.
   
   

   The treatment plan should be updated as the patient's condition changes.  Treatment plans should be maintained in the medical records.

2. Manipulation performed repetitively to maintain a level of function is not eligible for reimbursement. A participating, preferred or network provider cannot bill the member for the denied services. A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Maintenance therapy should be reported under procedure code S8990.

Coverage for manipulation of the spine is determined according to individual or group customer benefits.  Participating, preferred and network providers cannot bill the member for denied services that exceed the member's benefit limitations.

Refer to Medical Policy Bulletin Y-1 for information on Dry Hydro Massage.

Description

Manipulation (98925-98929, 98940-98943) is a passive maneuver in which a joint(s) is suddenly moved beyond the normal physiological range of movement without exceeding the boundaries of anatomic integrity. This treatment may be accomplished by a variety of techniques. The most common techniques include short lever, high velocity manipulation directed at a specific vertebra or joint for the purpose of taking the joint to the paraphysiological ranges of motion in the treatment of subluxation; and long lever, low velocity manipulation intended to correct or impact numerous vertebrae or joints at one time for the purpose of relieving somatic dysfunction.

The typical manipulation service for a patient includes a progress report from the patient and brief physical examination which determines the method, location, and intensity of the manipulation, if it is medically indicated.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

FEP:  For the FEP Basic Option benefit, only the following codes are covered spinal manipulative services:

• 98940-chiropractic manipulative treatment; spinal one to two regions



• 98941-spinal, three to four regions



• 98942-spinal, five regions

Payment will be made for 20 manipulations per calendar year.

PRN References

12/1993, Spinal manipulation and medical care
06/1994, Manipulation 04/1996, Manipulation therapy
06/1996, Manipulation and physical therapy
10/1996, Manipulation and physical therapy changes
10/1996, Therapy treatment plan
12/1996, Manipulation and physical therapy treatment plan: tips for completing form 3861
02/1997, Manipulation and physical therapy update
02/1998, Manipulation therapy codes change
08/1999, Manipulation therapy reporting guidelines reminder
06/2002, Manipulation and physical therapy reporting changes explained
08/2002, Highmark deletes routine maintenance therapy code, W9700
08/2003, Reminder: report evaluation and management codes with manipulation therapy services only under certain circumstances
02/2005, How to report maintenance manipulations
02/2005, Massage therapists services not eligible
04/2005, Manipulation services guidelines clarified

Table 1: Severity Grading for Chiropratic Conditions

Overall severity takes into consideration the above three factors. Once the severity of each component has been determined, the clinician should use the overall severity to determine the number of visits or weeks of treatment.

Standard Treatment Duration for Chiropractic Care

For any diagnosis not listed, treatment plans may be reviewed on an individual consideration basis.

Cervical

Thoracic

Lumbar

Prior episode, exacerbation, duration of onset prior to receiving treatment, Arthritides, congentital anomities may extend recovery 1.5-2x. The Chiropractor must be able to document continued improvement and show reason for the recovery being extended beyond normal range.

For further coding and billing documentation information, see Attachment A

ATTACHMENT A

Billing/Coding/Physician Documentation Information:

Applicable codes; 99201-99205, 99211-99215, 97010-97028, 97032-97039, 97110-97799, 98940-98943, S9090, 95831-95904

Constant Attendance Modalities, 97110-97036, and Theraputic Procedures, 97110-97542, will be limited to a maximum of one hour (4 units) for the combinations of codes submitted.

97140 services will be denied as intergral of mutually exclusive  98940-98943 services unless submitted with a 59 modifier, indicating a distinct procedural service.

MSBCBS may request medical records for determination of  medical mecessity.  When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentations unless all specific information needed to make a medical necessity determination is included.

Medical records may be requested when the scope, duration or frequency of chiropractic care exceeds the guidelines above: or if a modifier (e.g., 59) is used more frequently than expeceted or may not be consistent with claims history.

Records requested should include:

1. 
   
   Office visit notes:
   
   
   
   
   
   • 
     
     patient name, identifying number, and date of visit
     
     
   
   
   
   • 
     
     physical exam
     
     
   
   
   
   • 
     
     diagnostic studies and results
     
     
   
   
   
   • 
     
     results of previous treatments
     
     
   
   
   
   • 
     
     planned treatments and/or diagnostic studies
     
     
   
   
   
   • 
     
     communication to referral souce (when appropriate)
     
     
   
   
   
   • 
     
     follow-up
     
     
   
   
   
   



2. 
   
   Diagnostic x-rays and/or x-ray reports:
   
   
   
   
   
   • patient name, identifying number and date of procedure
   
   
   
   • name of provider performing and interpreting the study
   
   
   
   • clear directional markers
   
   
   
   • specific description and diagnosis of x-ray findings
   
   
   
   • overall treatment plan