CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPO16

Chiropractic Care Services

Governs billing, coding, documentation, and reimbursement standards for chiropractic manipulative treatment and related services provided to Blue Cross Blue Shield of Illinois members.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyChiropractic Care Services

Policy CodePolicy CPCPO16

Change TypeRevised documentation and coding standards

Effective DateJun 20, 2025

Next Review DateJun 12, 2025

Key ActionSubmit accurate documentation and supporting records upon request; claims are subject to review against benefit coverage, contract and coding policies.

SourceLink

POLICY UPDATE CHANGES

Documentation Standards and Coding Standards language was revised; CMT code table and E/M & CMT coding language were added.

98940-98943CMT codes specified

≤90 daysPlan duration limit

BiannualDiagnosis updates

Coverage Criteria and Rules

Coverage criteria and rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Records must include dates of service, legible notes, and direct one-on-one timed contact time for timed codes
Include subjective history describing chief complaint, changes since prior visit, response to care, and progress relative to treatment plan outcome measures
Include objective examination findings to verify diagnosis codes and demonstrate changes in response to care
Document treatment details and medical rationale for each manipulation or procedure, the member's immediate response, and instructions provided
Record the initial diagnosis and an assessment of the member's progress at each visit, with rationale for continued care or change in therapeutic direction
Maintain a written plan of treatment stating type, amount, frequency, duration, specific treatment goals, anticipated time frames, and objective measures to evaluate effectiveness

ALL of the following

Treatment plan is not valid for longer than 90 calendar days from the first treatment under the certified treatment plan

ALL of the following

Document location of pain/condition being treated and how the member tolerated the adjustment (response increased, reduced, or eliminated)
Document the specific regions adjusted and the technique used; each manipulation must relate to a symptomatic spinal or extraspinal level

ALL of the following

All CMT CPT codes (98940-98943) must be supported by ICD-10-CM diagnosis codes that justify the level of care and region count
Update diagnosis and coding for every new episode, including re-exams; some codes require higher specificity (7th digit) when applicable

E/M and CMT billing rules

Do not routinely bill an office/outpatient E/M code (99202-99205, 99211-99215) on the same day as CMT because CMT includes a brief pre-manipulation assessment; E/M may be billed when CPT E/M guidelines are fully met (eg, significant, separately identifiable evaluation)
Do not bill an E/M code in place of a CMT code; bill the code that best describes the service rendered

ALL of the following

Each CMT CPT code reflects the number of regions treated regardless of how many manipulations within a region (eg, C3 and C5 treated = one cervical region -> report 98940)
When billing codes that require multiple regions (eg, 98941 requires at least three different regions), ensure diagnosis codes support the region count

ALL of the following

Imaging must be obtained based on clinical need and be of sufficient diagnostic quality
Imaging information must be correlated with patient management and include a documented interpretation to reach diagnostic conclusions
Selection for radiographic examination must be based on history and physical findings, used to diagnose pathology or identify contraindications, and routine screening radiography is not appropriate

ALL of the following

Providers must maintain and submit accurate supporting documentation upon request; claims are subject to review against benefit coverage, contract terms, medical, clinical payment and coding policies, and code edit protocols

Chiropractic Manipulative Treatment (CMT) Coding

Chiropractic Manipulative Treatment (CMT)CPTCovered

98940	Chiropractic adjustment 1-2 regions in the spinal region
98941	Chiropractic adjustment 3-4 regions in the spinal region
98942	Chiropractic adjustment 5 regions in the spinal region
98943	Non-spinal adjustment 1 or more regions in the extraspinal regions

Region-count requirement for CMT

RequirementCPT codes 98940-98943 reflect the number of anatomic regions treated; multiple levels within the same region count as a single region (e.g., C3 and C5 billed as one cervical region -> 98940 when 1-2 regions).

ExampleManipulation of C3 and C5 during the same visit represents treatment to one region (cervical) and should be reported with CPT code 98940.

Code-to-region mapping98940: 1-2 spinal regions; 98941: 3-4 spinal regions; 98942: 5 spinal regions; 98943: non-spinal (extraspinal) 1+ regions.

Diagnosis linkageAll CMT CPT codes must be supported by ICD-10-CM diagnosis codes that justify the number of regions billed.

Documentation and Claim Review Requirements

Documentation Required

Documentation and claim review — submit accurate records and respond to requests

Providers must submit accurate, legible documentation of services performed and be prepared to provide supporting records upon request. Claims are subject to review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and code edit protocols; failure to adhere to coding and billing policies may affect claims processing and reimbursement.

Submit claims using valid HIPAA-approved code sets and industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG guidance, CCI edits, etc.).
Retain and furnish supporting documentation when requested to substantiate dates of service, services rendered, medical necessity, and coding linkage.
Expect claim review against plan documents, provider contracts, medical and coding policies, and automated code-edit logic.

Key Definitions

Chiropractic Manipulative Treatment (CMT)

DefinitionChiropractic Manipulative Treatment (CMT): high-velocity, short‑lever, low‑amplitude thrusts by hand or instrument to remove structural dysfunction in spinal and extraspinal regions.

Spinal regionsIncludes cervical, thoracic, lumbar, sacral, and pelvic regions (manipulative treatment of these regions).

ExtraspinalManipulative treatment of the appendicular skeleton (non‑spinal).

Documentation noteEach manipulation reported must be related to the patient’s complaints and a relevant symptomatic spinal or extraspinal level; documentation must list specific regions adjusted and technique used.

Maintenance care

DefinitionMaintenance care: ongoing or supportive treatment begun after therapeutic goals have been achieved or when no additional functional progress is expected (clinical plateau/Maximum Therapeutic Benefit).

Reimbursement stanceMaintenance and supportive care are not eligible for reimbursement.

When it beginsMaintenance begins when therapeutic goals are achieved or no additional functional progress is apparent or expected.

PurposeActivities that preserve the patient’s present level of function and prevent regression.

Qualified Healthcare Professional (QHP)

DefinitionQualified Healthcare Professional (QHP): an individual qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

ScopeQHPs provide professional services within their scope of practice and must hold applicable licensure, certification, or registration as required by state board/agency.

Limits on nonqualified personnelNonqualified personnel who do not meet the QHP definition are limited to non‑skilled services and may not bill direct treatments, modalities, or procedures.