Medicare Advantage

Chiropractic Services
MA10.004g

Policy

In accordance with the Centers for Medicare & Medicaid Services (CMS), chiropractic services are covered when both the established coverage criteria and the Medical Necessity criteria, listed in this policy, are 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. Services reported without one of these primary diagnosis codes and the AT modifier will be considered not covered.

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.
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; and
  • A significant major artery aneurysm near the proposed manipulation.
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.

LIMITATIONS

In accordance with Medicare, this policy imposes diagnosis limitations and will cover up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulations per member per calendar year. Please note that despite covering up to these maximums, each individual's condition and response to treatment must warrant the number of services reported. It is not expected that individuals will routinely require the maximum covered number of services.

Diagnoses that are considered medically necessary are displayed in four groups: it is not expected that more than the following number of treatments per diagnostic group will usually be required.
    A. Chiropractic manipulation treatments for Group A diagnoses are 12 visits.
    B. Chiropractic manipulation treatments for Group B diagnoses are 18 visits.
    C. Chiropractic manipulation treatments for Group C diagnoses are 24 visits.
    D. Chiropractic manipulation treatments for Group D diagnoses are 30 visits.
For information related to Group A, Group B, Group C, and Group D diagnosis codes, please see the coding table.

NOT MEDICALLY NECESSARY

All other diagnoses other than those listed in groups A, B, C, and D are considered not medically necessary and, therefore, not covered.

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
  • Xray, 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)), lumbo-sacral (L5 and sacrum), and sacro-iliac (sacrum and ilium)
Area of SpineNames of VertebraeNumber of VertebraeShort 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

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, chiropractic services are covered under the medical benefits of the Company’s Medicare Advantage products when the coverage criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

Additional chiropractic manipulation services may be available based on the member's evidence of coverage.

Description

According to Medicare, chiropractic services are performed through the means of manual manipulation (i.e., by use of the hands) of the spine.

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, identified by X-ray or physical exam in which the result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the individual's condition. Chronic subluxation is defined as an existing injury that is not expected to significantly improve or be resolved with further treatment 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, 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 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.


References

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. §240: Chiropractic Services. [CMS Web site]. 07/12/19. Available at: http://www.cms.gov/media/125221. Accessed December 5, 2019.

Centers for Medicare & Medicaid Services.(CMS) Misinformation on Chiropractic Services. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1601.pdf. Accessed December 5, 2019.

Novitas Solutions Inc. Local Coverage Article(A52987). Chiropractic Services [Novitas Solutions Web site]. Original 10/01/2015. Revised 03/27/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52987&ver=17&Date=12/05/2019&SearchType=Advanced&ContrId=&DocID=A52987&bc=JAAAABgAAAAA&. Accessed December 5, 2019.

Novitas Solutions Inc. Local Coverage Determination.(LCD) L35424. Chiropractic Services.[Novitas Solutions Web site] Original 10/01/2015. (Revised: 03/27/2019). Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35424&ver=38&Date=12/05/2019&SearchType=Advanced&DocID=L35424&search_id=&service_date=&bc=KAAAABgAAAAA&. Accessed December 5, 2019.

Coding

CPT Procedure Code Number(s)
COVERED
98940, 98941, 98942

NONCOVERED
98943

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)

​See Attachment A.


HCPCS Level II Code Number(s)
NOT COVERED

S8990 Physical or manipulative therapy performed for maintenance rather than restoration

Revenue Code Number(s)
N/A

Modifiers

AT Acute treatment

Coding and Billing Requirements

BILLING REQUIREMENTS

Claims submitted for chiropractic services (CPT codes 98940, 98941, or 98942) must include ALL of the following and are subject to the limitations outlined in this policy:
  1. A primary diagnosis code representing segmental and somatic dysfunction (International Classification of Disease [ICD] ICD-10 diagnosis codes (M99.00, M99.01, M99.02, M99.03, M99.04, M99.05).
  2. A secondary diagnosis code from one of the diagnosis groups A, B, C, or D which are listed within attachment A of this policy.
  3. The acute treatment (AT) modifier.

Policy History

10/1/2020
10/14/2020
6/2/2021
MA10.004
Medical Policy Bulletin
Medicare Advantage
{"2693": {"Id":2693,"MPAttachmentLetter":"A","Title":"Medically neessary ICD-10 diagnosis codes","MPPolicyAttachmentInternalSourceId":5518,"PolicyAttachmentPageName":"e2c6377a-eccf-4ce0-93b9-e85e2d45885c"},}
No