Chiropractic and Osteopathic Treatment

Policy ID: NDRP-GC-028

Section: Coding Billing

Effective Date: April 15, 2023

Revision Effective Date: June 15, 2026

Last Reviewed: March 18, 2026

Applies To: Commercial and Medicaid Expansion

Description

This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement of Chiropractic and Osteopathic Treatments.

Definitions

Adjunctive Procedures

Physical measures such as mechanical stimulation, heat, cold, light, air, water, electricity, sound, massage, and mobilization.

Cavitation

The “pop” that occurs during a chiropractic adjustment. This happens when the vertebral surface is separated creating a vacuum that pulls in nitrogen gas.

Chiropractic Adjustment

A passive manual maneuver during which a joint complex is carried beyond the normal physiological range of motion that is applied articulations and that is intended to result in cavitation of the joint or reduce subluxation.

Chiropractic Manipulation Treatment

Chiropractic Manipulation Treatment (CMT), often referred to simply as chiropractic adjustment or spinal manipulation, is a form of manual treatment to influence joint and neurophysiological functions. It is a primary treatment method used by chiropractors.

Chiropractic Regions

Spinal Regions

Cervical
Thoracic
Lumbar
Sacral
Pelvic

Extraspinal Regions

Head
Lower and upper extremities
Rib cage
Abdomen

Maintenance Program

A therapy program that consists of activities that preserve the patient’s present level of function and prevents regression of that function. Maintenance therapy begins when the therapeutic goals of a treatment plan have been achieved or when no further progress is apparent or expected to occur.

Manipulation Therapy

A treatment involving the movement of the spinal or other body regions.

Osteopathic Manipulation Treatment

Osteopathic Manipulation Treatment (OMT) is a form of manual treatment applied by a physician or other qualified health care professionals (MDs and DOs) to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of over twenty different manual treatment techniques.

Osteopathic Regions

Spinal Regions

Cervical
Thoracic
Lumbar\Sacral

Extraspinal Regions

Head
Lower and upper extremities
Rib cage
Abdomen and visceral region
Pelvic

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Policy

BCBSND evaluates claims for proper reimbursement of chiropractic and osteopathic treatments, based on coding guidelines, diagnoses, and documentation provided.

When billing for Chiropractic and Osteopathic Treatments ensure the following requirements are met:

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.

Note: Medicaid Expansion Requirement - Effective June 15, 2026, modifier AT must be appended to all CMT codes (98940–98943) to indicate active/corrective treatment for acute or chronic subluxation. Claims submitted without this modifier will be denied as non-covered.

Note: Medicaid Expansion (ME) will apply these policy rules for claims processed through December 31, 2023, and after April 1, 2024. ME claims processed January 1, 2024, through March 31, 2024, will follow NDRP-GC-031 Medicaid Expansion - Chiropractic Services.

Chiropractic Manipulative Treatments

CMT is a form of alternative medicine that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine. 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

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 one or more regions

When reporting the CPT code 97140 in conjunction with CMT codes, there are six criteria that must be documented to validate the service:
- 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
- The clinical rationale for a separate and identifiable service must be documented e.g., contraindication to CMT is present
- Description of the manual therapy technique(s) Location
- Location e.g., spinal region(s), shoulder, thigh
- Time i.e., number of minutes spent in performing the services associated with this procedure meets the timed-therapy services requirement
- Append modifier 59 or an appropriate X modifier

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."

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.

Osteopathic Manipulative Treatments

OMT are a form of manual treatment applied by a physician or other qualified health care professionals (MDs and DOs) to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of different manual treatment techniques.

Techniques Involve:

The application of gentle pressure, stretching, and resistance to balance muscle and tissue mechanics.
Techniques range from slow, continuous pressure to quick, sudden movements to correct, for example, spine alignment.

Conditions Treated:

OMT is used for musculoskeletal issues like back/neck pain, sciatica, and sports injuries
It is also effective for tension headaches, migraines, carpal tunnel syndrome, asthma, menstrual pain, and digestive issues like IBS.

Goal:

Aims to improve range of motion, enhance blood flow, and remove barriers to motion, often allowing for reduced reliance on medication or surgery.

Difference from Other Care:

Unlike chiropractic care, which often focuses on high-velocity adjustments, OMT assesses and treats muscles, fascia, and the lymphatic system alongside the skeleton.

Osteopathic treatment claims must include at least one of the following codes:

98925 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).

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 Policy - Commercial | BCBSND
Correct Coding Policy - Medicaid Expansion | BCBSND
Manipulation Services | BCBSND
Manipulation Services - Medicaid Expansion | BCBSND
NDRP-GC-034 Evaluation and Management Policy

History

Date

Updates

3/6/23

Policy created.

8/16/2023

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.

9/6/2023

Language updates, payment integrity edits and new link to the ME Chiropractic Services policy

3/28/2024

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.

9/24/2024

Added reference to NDRP-GC-034 Evaluation and Management Policy.

10/6/2025

Annual review completed. Updated reference links.

3/18/2026

Annual review. Changed name to include Osteopathic services, added definitions grid, treatment requirements and added Medicaid Chiropractic changes effective June 15, 2026.

Policy ID: NDRP-GC-028

Section: Coding Billing

Effective Date: April 15, 2023

Revision Effective Date: April 01, 2024

Last Reviewed: October 06, 2025

Archived Date: June 14, 2026

Applies To: Commercial and Medicaid Expansion

Description

This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement of Chiropractic Services.

Note: Medicaid Expansion (ME) will apply these policy rules for claims processed through December 31, 2023 and after April 1, 2024. ME claims processed January 1, 2024, through March 31, 2024 will follow NDRP-GC-031 Medicaid Expansion - Chiropractic Services.

Definition

98940

Chiropractic manipulative treatment (CMT); spinal, 1-2 regions

98941

Chiropractic manipulative treatment (CMT); spinal, 3-4 regions

98942

Chiropractic manipulative treatment (CMT); spinal, 5 regions

98943

Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

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.

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

Massage Therapy Exclusion

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.