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
BCBSND follows the North Dakota Medicaid Chiropractic manual and guidelines for Medicaid Expansion members receiving services by a Chiropractor. New patient Evaluation and Management (E/M) Services, chiropractic manipulation and spinal x-rays are reimbursable. All other services will not receive separate reimbursement.
Evaluation and Management (E/M) Services
According to Medicaid Expansion the new Patient E/M services (99202 or 99203) are reimbursed in addition to the chiropractic manipulative treatment (98940-98942) only when the patient has not received any professional (face-to-face) services from the chiropractor, or another chiropractor of the same group practice, within the past three years.
Radiology Services
Reimbursement for X-Rays are limited to radiological examinations of the full spine; the cervical, thoracic, lumbar, and lumbosacral areas of the spine only.
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
