When a benefit, manipulation for all body regions should be paid in accordance with the guidelines outlined in this policy.

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.  Manipulations should be provided in accordance with an ongoing, written treatment plan and must be appropriate for the diagnosis reported.  The treatment plan should include: 

• The specific modalities/procedures to be used in treatment;
• Diagnosis;
• The region treated;
• 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.

Manipulations can be provided manually or with the assistance of various mechanical or computer operated devices.  No additional payment is available for use of the device or for the device itself.  A participating, preferred, or network provider cannot bill the member for these denied services.

NOTE:  The FRAS system (Forced Recording and Analysis System) is a device that provides two functions.  It analyzes intervertebral resistance and it also can be programmed to provide a low force mechanical thrust to the vertebrae.  The use of this device is considered part of manipulation and should not be reported separately.

Manipulation should be reported using codes 98925-98929 and 98940-98943.

The pre-, intra-, and post-service components of a manipulation service include:

• An update of the patient's history regarding any changes positive or negative since the prior visit.
• A review of the chart, prior treatment plan, or diagnostic imaging.
• Performance of an assessment to determine the location and intensity of the patient's symptoms and medical necessity of the manipulation (with or without use of an instrument as the assessment tool, e.g., FRAS System).
• Manual palpation that documents pain or tenderness including location, intensity, quality, tissue response of muscles (spasms, hypertonicity, etc.).
• Motion palpation, joint evaluation, or whatever technique is used to locate and evaluate joint dysfunction/fixations.
• The manipulation of the joint(s) identified in the evaluation to restore normal joint motion/mechanics.  Proper documentation of each area manipulated also must be noted in each daily note including technique or instrumentation used if not done by hand.
• A post-manipulation evaluation of the patient's response to the treatment should be noted.
• A determination to continue, cease or minimally alter the treatment plan.
• Patient education or instructions.

Evaluation and Management Services

Manipulation (98925-98929, 98940-98943) includes a pre-manipulation assessment.  Time-based physical medicine services (97032-97036, 97110-97124, 97140) also include the time required to perform all aspects of the service, including pre-, intra-, and post-service work. Therefore a separate evaluation and management (E/M) (99211-99215) service must be medically necessary.  A separate E/M service should not be routinely reported with manipulation or time-based physical medicine services. This means that a separate evaluation and management (E/M) service should only be paid in the following circumstances:

• initial examination of a new patient or condition;
• acute exacerbation of symptoms or a significant change in the patient's condition; or
• distinctly different indications, which are separately identifiable and unrelated to the manipulation

When reporting evaluation and management services, the level reported should be consistent with the complexity of the history, physical and medical decision making involved in the patient encounter.  Documentation in the medical record should include the components of the separate and distinct evaluation and management service as well as the reasons for performing the separate evaluation and management service.

When medical care is reported for any of the three reasons cited above, report modifier 25 with the evaluation and management service to identify it as a separately identifiable service, in accordance with these guidelines.

Physical Medicine Modalities

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.

Joint mobilization (97140) uses low velocity, low amplitude, long lever maneuvers to increase range of motion in patients with decreased passive range of motion.  It can be used to treat spinal or extraspinal conditions.  Code 97140 is considered an inherent part of a manipulation procedure and is not eligible for separate payment when reported on the same day as the manipulation. Participating, preferred, and network providers cannot bill the member for these denied services.

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. For example, patients may experience referred symptoms, such as sciatica to an extremity caused by spinal misalignment. In such cases, treatment of the causative diagnosis, (e.g., spinal misalignment), is medically necessary.  However, separate treatment of the extremity is considered medically necessary only if objective findings demonstrate a distinct, unrelated physical problem with the extremity.  Otherwise, the treatment to the extremity will be considered related to the primary service (treatment of spinal misalignment). 

When codes 97010, 97124 and 97140 are performed on a separate body regions, unrelated to the manipulation procedure, modifier-59 should be reported with codes 97010, 97124, or 97140.  The patient's medical record must include documentation identifying the distinct body regions and diagnoses for which these services were provided.  A region includes all muscles or ligaments attached to the region being treated.  For example, the trapezius muscle is in the same region as the cervical and thoracic spine.

Procedure code 97750 [Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes] should not be used to report the physical assessment routinely performed as part of either the manipulation or the E/M service.  Assessments performed during a manipulation or as part of an Evaluation and Management encounter include the assessment of muscle strength, ROM, flexibility and endurance to establish the diagnosis and severity of the condition.  For example, a patient with a shoulder strain would undergo resistive testing in various movements to determine the muscle group or motion that has been injured.  It is also not appropriate to use code 97750 to report computer generated information obtained through devices such as the FRAS system.  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.  When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.  Modifier 25 may be reported with medical care (e.g. visits, consults) to identify it as significant and separately identifiable from the other service(s) provided on the same day.  When modifier 25 is reported, the patient’s records must clearly document that separately identifiable medical care was rendered.

Maintenance Services

Manipulation performed repetitively to maintain a level of function are not eligible for reimbursement. A participating, preferred, or network provider can 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 can 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.

Documentation

Documentation must include the following to validate the appropriateness of the manipulation:

• A record of the patient’s subjective complaint,
• An objective assessment or physical findings to support the manipulation,
• A clear description of the type of adjustment provided, including the body region to which the adjustment was performed, and,
• A post-manipulation evaluation of the patient’s response to the treatment.

The five spinal regions referred to in the description for codes 98940-98942 are: cervical (includes atlanto-occipital joint), thoracic (includes costovertebral and costotransverse joints), lumbar, sacral, and pelvic sacro-iliac joint).

Report services based on the number of regions manipulated; for example, if two regions are manipulated, report code 98940.  If more than one segment is manipulated in a single region, it is still considered one region for reporting purposes.

The five extraspinal regions identified for code 98943 are: the head (including temporomandibular joint, excluding the atlanto-occipital, lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral joints), and abdomen.

Procedure code 98943 describes treatment to one or more extraspinal regions; therefore, report the service once regardless of how many individual extraspinal manipulations are performed.

Ten regions are identified for codes 98925-98929.  These include: head; cervical; thoracic; lumbar; sacral; pelvic; lower extremities; upper extremities; rib cage; and, abdomen and visceral.

The documentation may include these phrases: spinal manipulation, spinal adjustment, manual adjustment, manual manipulation, chiropractic adjustment, chiropractic manipulation, osteopathic manipulation, or abbreviations such as CMT or OMT.  It is also appropriate to record the actual chiropractic or osteopathic technique being employed.

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 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. 

*It is not always possible to move the joint beyond the normal physiological range of motion.

In addition, manipulation (98925-98929, 98940-98943) is a form of treatment intended to influence joint and neurophysiological function.  It uses controlled force, leverage, direction, amplitude and velocity, which are directed at specific joints or anatomical regions.  Manipulations can be performed manually or with use of devices (e.g., the FRAS system).

Specific to chiropractic manipulation, there are many techniques used to assist in or provide the service.  These techniques include, but are not limited to:

• Gonstead
• Diversified
• Toggle recoil
• Thompson drop
• Flexion-distraction
• Activator
• FRAS
• Arthrostim
• Pro-adjuster
• Upper cervical orthogonal instrument
• Cox Flexion-Distraction

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, and a decision to continue with the treatment plan.

A more commonly used term for a manipulation is "adjustment."  However, for the purposes of this policy document, the term manipulation, rather than adjustment, will be used.

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

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 covers the initial office visit, initial set of x-rays and spinal manipulations.  Standard Option and Basic Option each have manipulation limits per calendar year.

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

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