Mountain State Medical Policy Bulletin |
Section: | Therapy |
Number: | Y-9 |
Topic: | Manipulation Services |
Effective Date: | August 1, 2005 |
Issued Date: | August 1, 2005 |
Date Last Reviewed: | 08/2005 |
Indications and Limitations of Coverage
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:
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:
Chiropractic Services are not covered in any of the following circumstances:
The following treatments, procedures and/or diagnostic tests are covered when ordered within standard chiropractic care:
Medical necessity criteria - The chiropractor must justify medical necessity for continued chiropractic treatments and must be able to document the following:
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:
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:
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. |
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98925 | 98926 | 98927 | 98928 | 98929 | 98940 |
98941 | 98942 | 98943 | S8990 |
FEP: For the FEP Basic Option benefit, only the following codes are covered spinal manipulative services:
Payment will be made for 20 manipulations per calendar year. |
PRN References 12/1993, Spinal manipulation and medical care |
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:
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