Chiropractic Manipulation Diagnosis Policy

Effective Date: October 14, 2019

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:
In accordance with CMS, Horizon NJ Health shall reimburse Chiropractic Manipulation (CPT codes 98940-98942) only if it is billed with all three (3) of the following:

  1. A primary diagnosis of subluxation, including the level of subluxation;
  2. A supporting secondary diagnosis; and
  3. Modifier -AT (Acute treatment)

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)

Procedure:
Horizon NJ Health shall deny 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:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • 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.

References:

Local Coverage Article: Billing and Coding: Chiropractic Services (A52987) cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52987&ver=14&LCDId=35424&Date=&DocID=L35424&bc=iAAAABABAAAA&

Local Coverage Determination (LCD): Chiropractic Services (L35424) cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35424&ver=35&Date=&DocID=L35424&bc=iAAAABABAAAA&

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