State mandates do not automatically apply to all plans; therefore, individual group benefits must be verified.
CHIROPRACTIC SPINAL AND EXTRASPINAL MANIPULATION THERAPY
Chiropractic spinal and extraspinal manipulation therapy 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 professional provider
If no improvement is documented within the first 2-week course of treatment, the chiropractic treatment should be modified and performed for another 2-week course of treatment. If there is no documented improvement after 4 weeks of treatment even with modifications, additional treatment is considered not medically necessary and, therefore, not covered.
If the initial course of treatment (2-week or 4-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.
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 manipulation as part of a goal-directed, functionally based restorative treatment plan on a short-term basis may be appropriate in individuals with extraspinal 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 manipulation is 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 is a misrepresentation of the actual service rendered. These services are subject to post payment review and audit procedures.
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 3 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.
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 healthcare 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.
Chiropractic manipulation for the treatment of non-neuromusculoskeletal conditions (e.g., attention-deficit hyperactivity disorder (ADHD), asthma, infantile colic, depression) 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.
NOT MEDICALLY NECESSARY
The continued treatment of an individual when the maximum therapeutic goals of a treatment plan have been achieved and no additional functional improvement is apparent or expected to occur, sometimes referred to as maintenance therapy, is considered not medically necessary and therefore not covered because the provision of services has ceased to be of therapeutic value.
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 healthcare 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 healthcare 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 Current Procedural Terminology (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.
