Effective Date: October 14, 2019
Last Updated: July 25, 2021

Purpose:
This policy provides guidelines for reimbursement of Chiropractic Manipulation services.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• CPT Code 98940: Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
• CPT Code 98941: Chiropractic manipulative treatment (CMT); spinal, 3-4 regions
• CPT Code 98942: Chiropractic manipulative treatment (CMT); spinal, 5 regions

Policy:
Horizon NJ Health will consider for reimbursement Chiropractic Manipulation (CPT codes 98940-98942) only if it is billed with the following:

1. A primary diagnosis of subluxation, including the level of subluxation; and
2. A supporting secondary diagnosis

Examples of subluxation diagnoses:

• Head (ICD-10 code M99.00)
• Cervical (ICD-10 code M99.01)
• Thoracic region (ICD-10 code M99.02)
• Lumbar (ICD-10 code M99.03)
• Sacral (ICD-10 code M99.04)
• Pelvic (ICD-10 code M99.05)

Examples of supporting secondary diagnoses:

• Sacroiliitis and unspecified inflammatory spondylopathies (ICD-10 codes M46.1, M46.90-M46.99)
• Migraine with aura (ICD-10 code G43.109)
• Congenital musculoskeletal deformities of spine (ICD-10 codes Q67.5, Q76.3, Q76.425-Q76.429)
• Hereditary motor and sensory neuropathy (ICD-10 code G60.0)
• Osteoarthritis (ICD-10 codes M15.0, M15.9, M19.90)
• Spondylolysis (ICD-10 codes M43.00-M43.19)
• Tension headache (ICD-10 code G44.209)
• Trigeminal nerve disorders (ICD-10 codes G50.0, G50.1, G50.8, G50.9)

Documentation within medical records for chiropractic services should support the number of regions billed as well as the diagnosis codes reported.

Procedure:
Horizon NJ Health will not consider for reimbursement Chiropractic Manipulation (CPT codes 98940-98942) when billed without a primary diagnosis of subluxation and a secondary diagnosis for the symptoms associated with the diagnosis of subluxation is not present.

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

References:

Local Coverage Article: Billing and Coding: Chiropractic Services (A52987) https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=58345&ver=12&DocID=A58345&bc=gAAAAAIAAAAA&

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

History: