Policy Statement
Our health plan evaluates claims for proper reimbursement of chiropractic and osteopathic treatments, based on coding guidelines, diagnoses, and documentation provided.
When billing for chiropractic or osteopathic treatments,
- All Current Procedural Terminology (CPT®) codes must have a supporting ICD-10-CM diagnosis code to justify the level of care provided
- Correct coding guidelines must be followed, including, but not limited to, utilizing appropriate modifiers and billed according to scope of practice.
- Chiropractic manipulation codes are only reimbursable to chiropractors
- Osteopathic manipulation codes are only reimbursable to MDs and DOs
- Diagnoses that only describe "pain" is not sufficient to support medical necessity for treatments. The precise level(s) of the subluxation(s) must be specified to substantiate a claim for manipulation of each spinal region(s).
- The primary diagnosis code must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation.
- Diagnoses that describe ‘all spinal regions’, ‘upper and lower spinal’ regions, and ‘all affected’ regions, do not support the service performed to the degree of specificity required.
Chiropractic Treatment by a Chiropractor:
CMT codes include a pre-manipulation patient assessment, the adjustment, and evaluation of the effect of treatment.
Pre-Service work may include a review of:
- the patient’s records
- their diagnostic tests
- communication with other providers
- the actual preparations for care
Intra-Service work would include:
- discussion about the service with the patient
- a pertinent evaluation and assessment of the patient
- the procedure performed
Post-Service work includes:
- an evaluation and discussion with the patient about the effect of treatment
- arrangement of additional services or referral to another provider
- discussion of the case with other providers
- review of literature about the patient’s condition
- documentation of the service
Evaluation and Management (E/M) Services
An examination includes inspection of the patient and review of diagnostic tests to diagnose disease or evaluate progress. Use of the E/M codes must be supported within the patient’s medical record.
According to the American Medical Association (AMA) Current Procedural Terminology (CPT) Manual, "Chiropractic manipulative treatment codes (98940 - 98943) include a pre-manipulation patient assessment. Additional E/M services may be reported separately using the modifier -25, if the patient's condition requires a significant, separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure."
Documentation in the patient’s record must support the additional E/M service.
An E/M would be appropriate to bill for the following situations:
- New Patient - a new patient is one who has not received any professional services from the chiropractor or another chiropractor in the same group practice within the past three years.
- Established Patient – New Injury or Exacerbation - the E/M is needed to obtain history and fully evaluate the patient's condition for an initial treatment plan or, in the event of an exacerbation, modify a previous treatment plan.
- Established Patient – Same Condition with lapse in care for 60 days – when an E/M is needed to obtain history and fully evaluate the patient's condition for recurrence of the same condition as previously treated to establish or modify a treatment plan with a lapse in care for 60 days.
For any of the above circumstances, a -25 modifier must be submitted on the E/M service if there was a significant separately identifiable E/M service to allow reimbursement. If the above circumstances are not met, the plan will not allow reimbursement as it is considered included in the CMT codes.
In addition to any other applicable codes and in accordance with governing state statutes and regulations, Chiropractic treatment claims must include at least one of the following codes:
98940 CMT; spinal, one to two regions
- Valid diagnosis for one or two spinal regions, and
- Documentation to support manipulative treatment in one to two regions of the spine (region as defined by CPT).
98941 CMT; spinal, three to four regions
- Valid diagnosis for three to four spinal regions, or
- Valid diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings, and
- Documentation to support manipulative treatment in three to four regions of the spine (region as defined by CPT).
98942 CMT; spinal, five regions
- Valid diagnoses for five spinal regions, or
- Valid diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings, or
- Valid diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings, and
- Documentation to support manipulative treatment in five regions of the spine (region as defined by CPT).
98943 CMT; extraspinal, one to five regions
- Validated diagnosis for one or more extraspinal regions for which manipulation has been shown to be both safe and effective, and
- Documentation to support manipulative treatment in one or more extraspinal regions (region as defined by CPT).
97140 Manual therapy techniques (e.g., mobilization, manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes.
- When reporting the CPT code 97140 in conjunction with CMT codes, there are six criteria that must be documented to validate the service:
1. Manipulation was not performed to the same anatomic region or a contiguous anatomic region e.g., cervical, and thoracic regions are contiguous; cervical and pelvic regions are noncontiguous
2. The clinical rationale for a separate and identifiable service must be documented e.g., contraindication to CMT is present
3. Description of the manual therapy technique(s) Location
4. Location e.g., spinal region(s), shoulder, thigh
5. Time i.e., number of minutes spent in performing the services associated with this procedure meets the timed-therapy services requirement
6. CPT code 97140 is appended with the modifier -59 or the appropriate –X modifier
Osteopathic Treatment:
Osteopathic treatment claims must include at least one of the following codes:
98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved
- Valid diagnosis for one or two body regions
- Documentation to support osteopathic manipulation in one to two body regions (region as defined by CPT).
98926 OMT; 3-4 body regions involved
- Valid diagnosis for three to four body regions
- Documentation to support osteopathic manipulation in three to four body regions (region as defined by CPT).
98927 OMT; 5-6 body regions involved
- Valid diagnosis for five to six body regions
- Documentation to support osteopathic manipulation in five to six body regions (region as defined by CPT).
98928 OMT; 7-8 body regions involved
- Valid diagnosis for seven to eight body regions
- Documentation to support osteopathic manipulation in seven to eight body regions (region as defined by CPT).
98929 OMT; 9-10 body regions involved
- Valid diagnosis for nine to ten body regions
- Documentation to support osteopathic manipulation in nine to ten body regions (region as defined by CPT).
S8990 Physical or manipulative therapy performed for maintenance rather than restoration
- Valid diagnosis for body regions
- Documentation to support osteopathic manipulation in body regions (region as defined by CPT).
References
Cross References
- Adm 129 - Correct Coding Guidelines
- Mod 103 - Modifier 25; Significant, Separately Identifiable Service
