Policy
Chiropractic service is a form of alternative medicine that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine. Chiropractic manipulation treatment (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 your medical record.
According to the 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, BCBSND will not allow reimbursement as it is considered included in the CMT codes.
Radiology Services
BCBSND will not reimburse for Computer Tomography (CT) scans and Magnetic Resonance Imaging (MRI) services when billed by a chiropractor for claims processed on or after the effective date of this policy. If these charges are billed it will be rejected as provider liable. This will allow BCBSND to better manage these high-cost radiology services.
Services billed for consultation on X-ray exams performed elsewhere (76140) will not be reimbursed for claims processed on or after the effective date of this policy, as BCBSND already reimburses for both the professional and technical component of most radiology services.
Massage Therapy Exclusion
BCBSND will not reimburse providers for massage therapy services (97124) if performed on the same region undergoing CMT for claims processed on or after the effective date of this policy. Massages that are provided as preparation for a physical medicine therapy or chiropractic manipulation are considered an integral part of the therapy.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
Correct Coding Guidelines - Commercial | BCBSND
Correct Coding Guidelines - Medicaid Expansion | BCBSND
Manipulation Services | BCBSND
Manipulation Services - Medicaid Expansion | BCBSND
NDRP-GC-034 Evaluation and Management Policy
History
Date
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Updates
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3/6/23
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Policy created.
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8/16/2023
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Policy was updated to indicate Medicaid Expansion (ME) will apply these policy rules for claims processed through December 31, 2023. ME claims processed January 1, 2024, and after will follow NDRP-GC-031 Medicaid Expansion - Chiropractic Services.
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9/6/2023
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Language updates, payment integrity edits and new link to the ME Chiropractic Services policy
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3/28/2024
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This policy is being updated to incorporate the Medicaid Expansion (ME) allowance of E/M codes 99211-99213 which were added into the BCBSND Manipulation Services (Medicaid Expansion) Medical Policy effective April 1, 2024. Due to this, the policy will now be applicable from a correct coding concept to ME. ME Coverage rules regarding E/M and CMT services were moved to the BCBSND Manipulation Services (Medicaid Expansion) Medical Policy effective April 1, 2024. Lastly, the policy application section has been added to the policy for transparency.
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9/24/2024
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Added reference to NDRP-GC-034 Evaluation and Management Policy.
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