Commercial

Medical Policy

Notification

Chiropractic Spinal and Extraspinal Manipulation Therapy

Notification Issue Date:

The version of this policy will become effective 05/18/2020.
The intent of this policy has not changed, although it has been modified to remove Maintenance Therapy as a benefit contract exclusion.
Diagnosis codes have been deleted from the policy.
The following CPT codes have been deleted from this policy: 97124, 97140, and 97010.
The following modifiers have been deleted from this policy:

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

Title:

Chiropractic Spinal and Extraspinal Manipulation Therapy

Policy #:

10.02.02k

Policy

State mandates do not automatically apply to self-funded groups; 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.

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.

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 OMT 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. Extraspinal regions are the following: head (excluding atlanto-occipital, including temporomandibular joint), lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral joints), and abdomen.

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

American Academy of Child and Adolescent Psychiatry (AACAP). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.

American Academy of Child and Adolescent Psychiatry. ADHD parents medication guide. [AACAP Web site]. 2020. Available at: ADHD_Medication_Guide-web.pdf (aacap.org). Accessed February 20, 2024.

American Chiropractic Association (ACA). “Clinical Practice Guideline: Chiropractic Care for Low Back Pain". [ACA Web site.] 2017. Available at:
https://www.acatoday.org/news-publications/research-review-clinical-practice-guideline-chiropractic-care-for-low-back-pain/. Accessed February 20, 2024.

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). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. §240: Chiropractic Services-General. [CMS Web site]. 01/11/2024. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed February 20, 2024.

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):277-284.

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):307-311.

New Jersey (NJ) Administrative Code. Title 10. Chapter 68: Chiropractic Services. New Jersey Register, Vol. 50 No. 11 (2018). Available at: https://www.state.nj.us/humanservices/providers/rulefees/regs/NJAC 10_68 Chiropractic Services.pdf. Accessed February 20, 2024.

Novitas Solutions Inc. Local Coverage Article (A58345). Billing and Coding: Chiropractic Services [Novitas Solutions Web site]. Original 10/01/2020. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=58345&ver=12&keyword=chiropractic services&keywordType=any&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=name&contractorName=6&sortBy=relevance&bc=1. Accessed February 20, 2024.

Salehi A, Hashemi N, Imanieh MH, et al. Chiropractic: Is it efficient in treatment of diseases? Review of systematic reviews. Int J Community Based Nurs Midwifery. 2015;3(4):244-254.

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):443-448.

Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

TO REPORT CHIROPRACTIC MANIPULATION, USE THE FOLLOWING CODES

98940, 98941, 98942, 98943

EXPERIMENTAL/INVESTIGATIONAL

22505

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

NOT MEDICALLY NECESSARY

S8990 Physical or manipulative therapy performed for maintenance rather than restoration

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

AT Acute Treatment

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

7/1/2024

Version Issued Date: