Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Chiropractic Spinal and Extraspinal Manipulation Therapy

Policy #:10.02.02i

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

Chiropractic spinal and extraspinal manipulation therapy (EMT) provided for either the initial treatment of an acute condition (e.g., acute mechanical joint pain) related to an acute medical episode, or the initial treatment of a reinjury or aggravation of a chronic condition (i.e., the additional permanent impairment or worsening of a previous injury or illness) is considered medically necessary and, therefore, covered when both of the following criteria are met:
  • The individual has a neuromusculoskeletal condition, and the available published literature supports the use of manipulation in treating the condition.
  • The manipulation is performed within the scope of practice by an eligible health care professional.

If no improvement is documented within the first two-week course of treatment, the chiropractic treatment should be modified and performed for another two-week course of treatment. If there is no documented improvement after four weeks of treatment even with modifications, additional treatment is considered not medically necessary and, therefore, not covered.

If the initial course of treatment (two-week or four-week, as described above) has provided significant functional gains and improvement toward the resolution of the individual's condition, additional treatment is considered medically necessary and, therefore, covered in accordance with the member's benefit contract limitations for as long as the individual continues to improve. Evidence that the individual is continuing to improve with the additional treatment must be documented in the medical record. Services provided in the absence of documented improvement are considered not medically necessary and, therefore, not covered.

Therapeutic goals must be established prior to treatment, and the clinical response must be monitored, documented, and adjusted to achieve the maximal therapeutic response.Any clinically necessary adjustments to therapeutic goals must be documented, along with the supporting symptoms and conditions that warranted a change in goals.

Maintenance therapy is when the therapeutic goals of a treatment plan have been achieved, no additional functional improvement is apparent or expected to occur, the provision of services for a condition ceases to be of therapeutic value, and the therapy is no longer considered medically appropriate or medically necessary. This includes maintenance services that seek to prevent disease, promote health, and prolong and enhance the quality of life. Maintenance therapy is a benefit contract exclusion and, therefore, not covered and not eligible for reimbursement consideration.

EXTRASPINAL MANIPULATION
Extraspinal manipulation is covered and eligible for reimbursement when performed within the scope of practice by eligible professional providers. This service should be reported using the comprehensive code that includes treatment to one or more body regions; it is only eligible once per date of service. Extraspinal manipulationas part of a goal-directed, functionally based restorative treatment planon a short-termbasis may be appropriate in individuals withextraspinal conditions. An initial course of treatment must result in significant functional gains to substantiate continued treatment. If no evidence of significant functional gains exists, ongoing extraspinal manipulationis considered not medically necessary and, therefore, not covered.

Extraspinal manipulation services are not covered and, therefore, not eligible for reimbursement consideration to any professional providers when the service is specifically excluded from their state board-defined scope of practice.

Effective, June 18, 2008, New Jersey chiropractors may manipulate articulations beyond those of the spine only when there is a causal nexus between a condition of the manipulated structure and a condition of the spine. (See Bedford v. Riello, 195 N.J. 210, 948 A.2d 1272 [2008].)

Therefore, New Jersey chiropractic providers are required to include the following documentation in the individual's records on the day of the treatment and to make the documentation available for review:
  • The individual's complaint(s)
  • Objective physical findings to support manipulation in a region and/or segment outside of the spine
  • Assessment of change in the individual's condition, as appropriate
  • A record of specific segments manipulated

The documentation must be based on the chiropractor's clinical judgement and justification supporting the use of extraspinal manipulation and demonstrating a causal nexus between a condition of the manipulated structure and a condition of the spine.

Clinical documentation must substantiate the need for adjusting specific regions of the spine and its related structures (extremities). This must correlate with the individual's health assessment, the clinical examination form, the history, and the diagnoses. The documentation must reveal a causal nexus or link between a condition of the manipulated structure and a condition of the spine. All records must be legible and understandable.

Reporting extraspinal manipulation services as an application of any other chiropractic modality service or procedure (e.g., Current Procedural Terminology [CPT] code 97140) is a misrepresentation of the actual service rendered. These services are subject to post-payment review and audit procedures. Extraspinal manipulation should only be reported using CPT code 98943.

ASSOCIATED SERVICES
Evaluation and Management (E&M) Services

E&M services are not eligible for separate reimbursement when provided in conjunction with chiropractic spinal manipulation, with the following exceptions:
  • When the initial E&M examination is for a new patient
    • A new patient is one who has not received any professional services from the professional provider, or another professional provider of the same specialty who belongs to the same group practice, within the past three years.
  • When the E&M service is provided for an established patient with an acute exacerbation of symptoms or a significant change in condition, or the E&M service is performed for a condition distinct from that of the chiropractic spinal manipulation
    • Professional providers should append Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service) to the appropriate E&M procedure code to indicate that a separate service has been performed.

When E&M services are provided, the level of E&M reported must reflect the appropriate level of service performed and must be documented in the individual's medical record.

Other Treatment Modalities

The Company does not provide reimbursement for services that are performed by someone other than an eligible health care provider (i.e., within their scope of practice) for either constant attendance modalities or therapeutic procedures. This includes massage therapists.

EXPERIMENTAL/INVESTIGATIONAL

Chiropractic spinal manipulation under anesthesia (MUA) is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agency, other health care professionals, therapies, and test reports.

Proper documentation in the medical record is the treating provider's responsibility and extends beyond an internal office communication. Specifically, any trained health care provider should be able to review a medical record and clearly understand the status of an individual on a visit-to-visit basis, his/her diagnosis, treatment plans, therapeutic goals, medical necessity or appropriateness of the treatment being rendered, and expected outcome from the prescribed plan of care.

The Company may conduct reviews and audits of services provided to our members, regardless of the participation status of the provider. This process will include, but is not limited to, review of all services related to the claim prior to payment and post-payment review/audit of paid claims. Reviews may initially focus on adequate documentation, the proper usage of CPT and Healthcare Common Procedural Coding System (HCPCS) codes according to the appropriate level of service provided, and the utilization of manipulation services. All documentation must be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, chiropractic spinal and extraspinal manipulation therapy is covered under the medical benefit of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as experimental/investigational or not medically necessary are not eligible for coverage or reimbursement by the Company. Services that are experimental/investigational are a benefit contract exclusion for all products of the Company.

BILLING GUIDELINES

Routine/regular ongoing care in the absence of documented significant functional gains and improvement in the individual's condition will be subject to review.

Chiropractic spinal manipulation therapy or extraspinal services should be reported using the applicable CPT code(s) depending on the number of regions treated (spinal manipulation: CPT codes 98940-98942) or the services provided (extraspinal manipulation: CPT code 98943).

OSTEOPATHIC MANIPULATIVE MEDICINE THERAPY (OMT) (VERSUS CHIROPRACTIC MANIPULATION)
Osteopathic manipulative medicine therapy is a system of diagnosis and management for somatic dysfunction performed by a licensed osteopathic physician; it is not limited to spinal and extraspinal manipulation.

Chiropractic spinal manipulation and osteopathic manipulative medicine are reported with separate and distinct CPT codes.

Only licensed osteopathic physicians should report OMT codes.

Description

DEFINITIONS

Chiropractic (therapeutic) manipulation, commonly referred to as spinal and extraspinal adjustment, manual adjustment, vertebral adjustment, or spinal manipulative therapy (SMT), is the treatment of the articulations of the spine and musculoskeletal structures, including the extremities, for the purpose of relieving discomfort resulting from impingement of associated nerves or other structures (e.g., joints, tissues, muscles). In spinal manipulation, manual or mechanical means may be used to correct a structural imbalance or subluxation related to distortion or misalignment of the vertebral column.

Subluxation is an alteration in alignment, movement integrity, and/or physiologic function of the spine in which contact between the surfaces of the joints remains intact. Subluxation may be acute or chronic. Acute subluxation is defined as a new injury in which manipulation may result in an improvement. Chronic subluxation is defined as an existing injury that is not expected to completely resolve with manipulation. Once an individual's condition becomes chronic, ongoing manipulation is considered maintenance therapy.

Extraspinal manipulation, also known as extraspinal manipulative therapy (EMT), is used to treat joint dysfunction outside of the vertebral column.

Maintenance therapy is a continuation of care and management of the individual when the therapeutic goals of a treatment plan have been achieved, no additional functional improvement is apparent or expected to occur, the provision of services for a condition ceases to be of therapeutic value, and the therapy is no longer considered medically appropriate or medically necessary. This includes maintenance services that seek to prevent disease, promote health, and prolong and enhance the quality of life.

Chiropractic spinal manipulation under anesthesia (MUA) may be performed as a closed treatment for vertebral fracture or dislocation. In the absence of vertebral fracture or dislocation, MUA, performed either with the individual sedated or under general anesthesia, is intended to overcome an individual's conscious protective reflex mechanism that may limit the success of chiropractic spinal manipulation or adjustment. Controlled clinical trials are considered particularly important to isolate the contribution of this intervention and to assess the extent of the expected placebo effect. The available published medical literature does not currently provide evidence to support the safety and/or effectiveness of chiropractic spinal manipulation under anesthesia.
References


Bedford v. Riello, 192 NJ 481, 932 A.2d 31 (NJ 2007). Granting disposition. Decided April 18, 2007.

Bedford v. Riello, 195 N.J. 210, 948 A.2d 1272 (2008).

Bedford v. Riello, 392 NJ Super. 270, 920 A.2d 693 (NJ Super. Ct. App. Div. 2007). Decision which holds that the scope of chiropractic is limited to spinal column adjustments and does not include adjustments of other joints. Decided April 18, 2007.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub. 100-02: Medicare benefit policy. Transmittal 23. [CMS Web site]. 10/08/04. Available at: http://www.cms.hhs.gov/Transmittals/downloads/R23BP.pdf. Accessed July 2, 2018.

Company Benefit Contracts.

Ferreira ML, Ferreira PH, Latimer J, et al. Does spinal manipulative therapy help people with chronic low back pain? Aust J Physiother. 2002;48(4):277-84.

Hurwitz EL, Morgenstern H, Harber P, et al. Second Prize: The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: findings from the UCLA low back pain study. J Manipulative Physiol Ther. 2002;25(1):10-20.

McMorland G, Suter E. Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis. J Manipulative Physiol Ther. 2000;23(5):307-11.

Novitas, Inc. Local Coverage Article for Chiropractic Services (A52987) Original Effective Date: 10/01/2017 Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52987&ver=11&ContrId=323&ContrVer=1&CntrctrSelected=323*1&Date=10%2f05%2f2015&DocID=A52987&bc=hAAAAAgAAAAAAA%3d%3d&. Accessed July 02, 2018.

Novitas, Inc. Local Coverage Determination. (LCD) L35424 - Chiropractic Services. Effective 10/01/2017. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35424&ver=24&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&. Accessed July 02, 2018.

Vernon HT, Humphreys BK, Hagino CA. A systematic review of conservative treatments for acute neck pain not due to whiplash. J Manipulative Physiol Ther. 2005;28(6):443-8.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

TO REPORT CHIROPRACTIC MANIPULATION, USE THE FOLLOWING CODES
98940, 98941, 98942

TO REPORT EXTRASPINAL MANIPULATION, USE THE FOLLOWING CODE (THIS SERVICE IS ONLY ELIGIBLE FOR NON-MEDICARE ADVANTAGE MEMBERS WHEN PERFORMED WITHIN THE SCOPE OF PRACTICE BY AN ELIGIBLE HEALTH CARE PROFESSIONAL PROVIDER)
98943

WHEN PERFORMED ON SEPARATE BODY REGIONS UNRELATED TO THE MANIPULATION PROCEDURE, THESE SERVICES MAY BE CONSIDERED FOR SEPARATE REIMBURSEMENT WHEN REPORTED WITH MODIFIER 59 IN THE FIRST POSITION FOR MEMBERS ENROLLED IN (PPO) COMMERCIAL PRODUCTS ONLY
97124, 97140

THE FOLLOWING SERVICE IS NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT
97010

THE FOLLOWING SERVICE IS CONSIDERED EXPERIMENTAL/INVESTIGATIONAL
22505


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Please see Attachment A


HCPCS Level II Code Number(s)



THE FOLLOWING CODE IS NOT COVERED AS IT IS A BENEFIT EXCLUSION AND MAY BE USED TO REPORT MAINTENANCE THERAPY

S8990 Physical or manipulative therapy performed for maintenance rather than restoration


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

AT Acute treatment

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

59 Distinct Procedural Service


Coding and Billing Requirements


Cross References

Attachment A: Chiropractic Spinal and Extraspinal Manipulation Therapy
Description: Medically necessary ICD-10 diagnosis codes




Policy History

Revisions from 10.02.02i
10/01/2018This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy: M79.10, M79.11, M79.12, M79.18. The following ICD-10 code have been termed from the policy: M79.1.

Revisions from 10.02.02h
08/01/2018As of 8/01/2018, this policy has been reviewed and reissued to communicate the Company’s continuing position on Chiropractic Spinal and Extraspinal Manipulation Therapy.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.