CurrentAlliance HealthPolicy Clinical Coverage Policy No: 1F

Chiropractic Services (NC Medicaid)

Defines Medicaid coverage, exclusions, provider qualifications, documentation, visit limits, and coding/billing rules for chiropractic services (manual manipulation of the spine) under NC Medicaid. Applies statewide to Medicaid beneficiaries, with EPSDT exceptions for beneficiaries under 21.

Policy Summary

PayerAlliance Health

PolicyChiropractic Services (NC Medicaid)

Policy CodePolicy Clinical Coverage Policy No: 1F

Change TypeMultiple subsection revisions and code updates (10/15/2024)

Effective DateJul 1, 1996

Next Review Date

Key ActionDocument initial visit findings, maintain and update a treatment plan with specific treatment goals, and ensure chiropractic claims list a primary spinal subluxation ICD-10-CM code.

SourceLink

POLICY UPDATE CHANGES

Added definitions for Chiropractor, Maintenance Care, Supportive Care, and Wellness Care; clarified Manual Manipulation.

Consolidated text previously under Manual Manipulation of the Spine and Subluxation into Subsection 3.2.1.1.

Added Documentation Requirements for the Initial Visit and removed prior requirement that treatment requires a primary diagnosis of subluxation with level affected.

Added 'specific treatment goals' to treatment plan requirements.

Added Visit Limits: combined optional services limited to eight per beneficiary per State fiscal year.

Changed primary ICD-10-CM diagnosis code set: removed M99.00-M99.08 and replaced with M99.10-M99.15; claims without a primary subluxation diagnosis will be denied.

Removed CPT 72069 (end-dated) from allowed x-ray codes.

3Required initial physical exam findings (choose 1 of 2 + 1 of 2)

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Primary ICD-10-CM spinal subluxation codes listed

8Combined optional services visit limit per SFY

Coverage Summary

This policy defines coverage for Chiropractic Services (manual manipulation of the spine) under NC Medicaid. It applies statewide to Medicaid beneficiaries and addresses provider qualifications, required documentation, coding/billing rules, exclusions, and visit limits. EPSDT allows exceptions for beneficiaries under 21 years when medically necessary (prior approval requirements still apply where required). Combined optional services (chiropractic, podiatry, and optometry) are limited to 8 visits per beneficiary per State fiscal year (July 1 - June 30).

Coverage thresholds

X-ray recency for initial documentationOne set of x-rays within six (6) calendar months prior to initial date of service

Initial improvement reviewImprovement must be documented within the initial two (2) calendar weeks or the treatment plan must be modified

Maximum continued treatment without improvementIf no improvement after thirty (30) calendar days of modified treatment, no additional treatment is allowed

Combined optional services visit limitCombined chiropractic, podiatry and optometry limited to 8 visits per beneficiary per State fiscal year (July 1 - June 30) per 42 CFR 440.225

Medical Necessity Criteria

General Medical Necessity Criteria

Covered when ALL of the following are met:

ALL of the following

Procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs.
Procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide.
Procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

Specific Coverage Criteria for Chiropractic Services

Medicaid shall cover chiropractic services when the beneficiary meets ALL of the following specific criteria:

Background and Definitions

Chiropractic manual manipulation (spinal adjustment) services are an optional Medicaid service. EPSDT provides an exception to policy limitations for beneficiaries under 21 years of age when the service is medically necessary to correct or ameliorate a defect, illness, or condition; documentation must show how the service meets EPSDT criteria and prior approval requirements remain where applicable. The policy requires documentation and specific coverage criteria for spinal subluxation and limits combined optional services to 8 visits per beneficiary per State fiscal year per 42 CFR 440.225.

Chiropractor: A licensed healthcare professional trained to provide manual manipulation of the spine for a diagnosis of subluxation.

Maintenance Care: A traditional chiropractic approach, whereby active treatment is continued after optimum benefit is reached.

Manual Manipulation: A procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit.

Motion Segment: A functional unit made up of the two adjacent articulating surfaces and the connecting tissues binding them to each other.

Subluxation: A motion segment in which alignment, movement integrity, or physiological function are altered although contact between joint surfaces remains intact.

Supportive Care: Periodic chiropractic treatments to maintain maximum therapeutic benefit.

Wellness Care: Includes nutritional supplements, hygienic modalities, environmental modalities, rehabilitation and physiotherapeutic modalities, massage therapy, counseling, beneficiary education, home exercises, and ergonomic postural modification as adjuncts to manual manipulation.

Coding

Covered CPT - Chiropractic manipulationCPTCovered

98940	Chiropractic manipulation, 1-2 regions
98941	Chiropractic manipulation, 3-4 regions
98942	Chiropractic manipulation, 5 regions

Permitted X-ray CPT codes for documentationCPTCovered

72020	Spine x-ray series - cervical (per policy mapping)
72040	Spine x-ray series - thoracic (per policy mapping)
72050	Spine x-ray series - lumbosacral (per policy mapping)
72052	Spine x-ray series - lumbosacral (alternate mapping)
72070	Spine x-ray - scoliosis/other (per policy mapping)
72072	Spine x-ray - other (per policy mapping)
72074	Spine x-ray - other (per policy mapping)
72080	Radiologic exam, spine; cervical
72081	Radiologic exam, spine; thoracic
72082	Radiologic exam, spine; lumbosacral

1–10 of 21

1/3

Primary ICD-10-CM diagnosis required (spinal subluxation)ICD-10Covered

M99.10	Segmental and somatic dysfunction of cervical region (vertebral subluxation of cervical region)
M99.11	Segmental and somatic dysfunction of thoracic region (vertebral subluxation of thoracic region)
M99.12	Segmental and somatic dysfunction of lumbosacral region (vertebral subluxation of lumbosacral region)
M99.13	Segmental and somatic dysfunction of sacral and sacrococcygeal region (vertebral subluxation of sacral region)
M99.14	Segmental and somatic dysfunction of other specified parts of spine
M99.15	Segmental and somatic dysfunction of unspecified parts of spine

Provider Actions and Billing Rules

Documentation Required

Initial visit documentation

Document chief complaint, current symptoms, relevant history, mechanism of trauma, symptom details (location, onset, provoking/palliative factors, quality, duration, frequency, intensity), prior interventions, physical exam, diagnosis, and affected vertebral levels at the beneficiary's first visit.

Chief complaint and current symptoms
Relevant family, medical, and surgical history
Mechanism of trauma
Symptom details: location, onset, provoking/palliative factors, quality, duration, frequency, intensity, character
Prior interventions, treatments, medications, secondary complaints
Physical examination findings
Diagnosis
Affected vertebral level(s)

Documentation Required

Treatment plan requirements

Revision History

10/15/2024revisedLatest

Subsection 1.1 updated: Added definitions for Chiropractor, Maintenance Care, Supportive Care, and Wellness Care; clarified Manual Manipulation.

10/15/2024revisedLatest

Subsection 3.2.1.1 updated: Consolidated text previously under Manual Manipulation of the Spine and Subluxation into Subsection 3.2.1.1.

10/15/2024

Policy Summary

PayerAlliance Health

PolicyChiropractic Services (NC Medicaid)

Policy CodePolicy Clinical Coverage Policy No: 1F

Change TypeMultiple subsection revisions and code updates (10/15/2024)

Effective DateJul 1, 1996

Next Review Date

Key ActionDocument initial visit findings, maintain and update a treatment plan with specific treatment goals, and ensure chiropractic claims list a primary spinal subluxation ICD-10-CM code.

SourceLink

On This Page

ALL of the following

A spinal subluxation is confirmed by a physical examination or by one (1) set of x-rays taken within six months prior to the initial date of service.One set of x-rays within six (6) calendar months prior to initial date of service
See permitted x-ray CPT codes in Attachment A and x-rays must be kept on file.
On physical examination prior to initiation of therapy, ONE of the following must be present
- Asymmetry or misalignment on a segmental or sectional level.
- Range of motion abnormality.
When one of the two physical exam conditions is present, ONE or BOTH of the following must also be present
- Pain or tenderness at the area of subluxation.
- Tissue tone, texture, or temperature abnormalities.

EPSDT Exception for Beneficiaries under 21

EPSDT allows exceptions to policy limitations for beneficiaries under 21 when medically necessary; prior approval requirements still apply if the service normally requires prior approval.

ALL of the following

Service meets EPSDT medical necessity to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening examination.
42 U.S.C. § 1396d(r)
Provider documentation must show how the service meets EPSDT criteria; state may exceed policy limits when documentation supports necessity.
If service requires prior approval under the policy, EPSDT does NOT eliminate the prior approval requirement.
See NCTracks Provider Claims and Billing Assistance Guide and EPSDT provider page.

Maintain a clear treatment plan that documents the symptoms/diagnosis, diagnostic procedures and treatment modalities used, results, specific treatment goals, and anticipated length of treatments. A copy of the treatment plan must be maintained in the beneficiary's chiropractic health record.

Symptoms or diagnosis treated
Diagnostic procedures and treatment modalities used
Results of diagnostic procedures and treatments
Specific treatment goals (required)
Anticipated length of treatments
Copy of the treatment plan kept in beneficiary's chiropractic health record

Documentation Required

Continued treatment monitoring

Monitor and document beneficiary response to care. Modify the treatment plan if improvement is not documented within the initial two calendar weeks. If no improvement is documented after thirty calendar days of modified treatment, no additional treatment is allowed. Stop care once maximum therapeutic benefit is achieved.

Review for improvement within initial 2 calendar weeks — modify and document plan if no improvement
If no improvement after 30 calendar days of modified treatment — no additional treatment allowed

Denial Risk

Primary diagnosis requirement

Chiropractic claims must list one of these primary ICD-10-CM spinal subluxation codes: M99.10, M99.11, M99.12, M99.13, M99.14, M99.15. Claims without a primary diagnosis of subluxation will be denied.

M99.10
M99.11
M99.12
M99.13
M99.14
M99.15

Billing Rule

X-ray documentation

One set of x-rays taken within six (6) calendar months may be used to document the musculoskeletal condition. Permitted spine x-ray CPT codes are listed in Attachment A; x-rays must be kept on file in the beneficiary's health record and are subject to post-payment review.

Permitted x-ray CPT codes include: 72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72081, 72082, 72083, 72084, 72100, 72110, 72114, 72120, 72170, 72190, 72200, 72202, 72220
X-rays must be on file in beneficiary health record
X-rays are subject to post-payment review

Billing Rule

Billing units

Manipulation of the spine may be billed only once per date of service.

Affected CPT codes: 98940, 98941, 98942 (chiropractic manipulation)

Billing Rule

Claim type and form

Professional (ambulatory) claims must be submitted on CMS-1500 / 837P. Institutional claims must be billed according to National Uniform Billing Guidelines and all claims must comply with National Coding Guidelines unless directed otherwise.

CMS-1500 / 837P for professional claims
Institutional claims per National Uniform Billing Guidelines and National Coding Guidelines

Documentation Required

Provider eligibility and verification

Verify Medicaid eligibility at each visit. Providers must meet Medicaid participation qualifications, have a current signed DHHS Provider Administrative Participation Agreement, and bill only within their licensed scope of practice.

Verify beneficiary Medicaid eligibility at every visit
Maintain current, signed DHHS Provider Administrative Participation Agreement
Bill only for services within the provider's scope of practice

Subsection 5.3 updated and previous text removed: Added Documentation Requirements for the Initial Visit and removed prior requirement that treatment requires a primary diagnosis of subluxation with level affected.

10/15/2024addedLatest

Subsection 5.4.d updated: Added 'specific treatment goals' to treatment plan requirements.

10/15/2024addedLatest

Subsection 5.6 added referencing 42 CFR 440.225: Added Visit Limits — combined optional services limited to eight per beneficiary per State fiscal year.

10/15/2024revisedLatest

Attachment A: Letter B updated — Changed primary ICD-10-CM diagnosis code set: removed M99.00-M99.08 and replaced with M99.10-M99.15; claims without a primary subluxation diagnosis will be denied.

10/15/2024revisedLatest

Attachment A: Letter C updated — Removed CPT 72069 (end-dated) from allowed x-ray codes.