Medicare Advantage

Medical Policy Bulletin

Policy

MPPolicyPub

In accordance with the Centers for Medicare & Medicaid Services (CMS), chiropractic services are covered when the established coverage criteria is met.

COVERAGE CRITERIA

Chiropractic services performed by means of manual manipulation (i.e., by use of the hands) of the spine are covered for the purpose of correcting a confirmed acute subluxation as a result of a new injury demonstrated by x-ray or physical examination. The result of chiropractic manipulation is expected to be an improvement in or an arrest of the progression of the individual’s condition.

Chiropractic spinal manipulation services are additionally covered for one of the following conditions and must be clearly documented and reflective of the individual’s symptoms and treatment history:

• Acute exacerbation is a temporary marked deterioration of the individual’s condition causing significant interference with the activities of daily living due to flare up of the previously treated condition.
• Recurrence of an acute condition is a temporary marked deterioration of the individual’s condition due to flare up of the condition being treated.​

A number of different terms maybe used to describe manual manipulation:

• Spine or spinal adjustment by manual means
• Spine or spinal manipulation
• Manual adjustment
• Vertebral manipulation or adjustment
  

Chiropractic spinal manipulation treatments must be reported with a primary diagnosis code representing an acute subluxation as well as the acute treatment (AT) modifier. 

NOT COVERED

Treatment for chronic subluxation and maintenance therapy are not covered by the Company because these services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

• Chronic subluxation: An individual's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.
• Maintenance therapy: Is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or as a therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. In accordance with Medicare, chiropractic maintenance therapy is considered not covered. Therefore, it is not eligible for reimbursement consideration. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and considered not covered.

In accordance with Medicare, all other services, other than manual manipulation for the treatment of acute subluxation of the spine, are not covered by the Company, including, but not limited to, laboratory tests, office visits, supplies, traction, treatment of joint dysfunction outside of the vertebral column (i.e., extraspinal) and manual devices. Therefore, they are not eligible for reimbursement consideration.

​Services reported without one of the primary ​diagnosis codes and the AT modifier will be considered not covered.

ABSOLUTE CONTRAINDICATIONS

Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation, and proposed manipulation in the following conditions and is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

• Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation, including acute rheumatoid arthritis and ankylosing spondylitis
• Acute fractures and dislocations or healed fractures and dislocations with signs of instability
• An unstable os odontoideum
• Malignancies that involve the vertebral column
• Infection of bones or joints of the vertebral column
• Signs and symptoms of myelopathy or cauda equina syndrome
• For cervical spinal manipulations, vertebrobasilar insufficiency syndrome
• A significant major artery aneurysm near the proposed manipulation

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 professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

The individual exhibiting a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment with the following required documentation, and manipulative services rendered must have a therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery:

• Individual’s health history
• Description of the present illness including the individual’s symptoms related to the level of subluxation
• Evaluation of the musculoskeletal/nervous system through physical examinination
• The precise level of the subluxation
• X-ray, CT scan, and/or MRI
• Treatment plan including duration and frequency of visits, treatment goals and objective measure to evaluate treatment effectiveness

The primary diagnosis documented must be subluxation, including the level of subluxation, either so stated or identified by one of the following descriptive terms for the nature of the abnormalities:

• Off-centered
• Misalignment
• Malpositioning
• Spacing—abnormal, altered, decreased, increased
• Incomplete dislocation
• Rotation
• Listhesis—antero, postero, retro, lateral, spondylo
• Motion-limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant

There are two ways in which the level of subluxation may be specified.

• The exact bones may be listed (e.g., C5, C6)
• The area may suffice if it implies only certain bones such as: occipito-atlantal (Occiput and C1 [atlas]), lumbosacral (L5 and sacrum), and sacroiliac (sacrum and ilium)

Area of Spine	Names of Vertebrae	Number of Vertebrae	Short form or Other name
Neck	Occiput	7	Occ, CO
	Cervical		C1 thru C7
	Atlas		C1
	Axis		C2
Back	Dorsal or	12	D1 thru D2
	Thoracic		T1 thru T12
	Costovertebral		R1 thru R12
	Costotransverse		R1 thru R12
Low Back	Lumbar	5	L1 thru L5
Pelvis	IIii, r and 1		I, Si
Sacral	Sacrum, Coccyx		S, SC

The chiropractor must document in the medical record the treatment phase or month of treatment for the services provided. In addition, it should be documented in the individual's medical record whether the individual has had an exacerbation (flare up while being treated) or recurrence (recurring after 90 days or more of no treatments) of a previously treated acute condition.

Guidelines

Description

References

Coding

CPT Procedure Code Number(s)

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)

HCPCS Level II Code Number(s)

Revenue Code Number(s)

MPMiscCodesNarrativesPub

Modifiers

Coding and Billing Requirements

Cross Reference

Policy History