Coverage follows Original Medicare limits with selected enhancements for participating group plans; payment and clinical criteria apply.
Services must be medically necessary and reasonable per Medicare standards; manipulative services must have a direct therapeutic relationship to the patient’s condition and provide a reasonable expectation of recovery or improved function.
For spinal manipulation (chiropractic manipulative treatment, CMT) the patient’s primary diagnosis must be subluxation of the spine and the precise level of subluxation must be specified by the chiropractor; subluxation may be demonstrated by X-ray or physical examination.
Modifier AT is required on claims for active or corrective spinal manipulation (e.g., CPT 98940-98942) when treating acute or chronic subluxation; claims without modifier AT are considered maintenance therapy and are denied under Original Medicare.
Original Medicare limits coverage to manual manipulation of the spine (by use of the hands); select Medicare Plus Blue Group PPO plans may provide enhanced coverage (diagnostic X-rays, evaluation & management services, mechanical traction, modalities) for participating groups per group determinations.
Frequency and visit limits: select group plans determine member cost sharing and frequency limits. Where specified for enhanced group plans: new patient E/M visits payable once every 36 months per chiropractor; established patient E/M visits payable once every 12 months per chiropractor (group-specific variation applies).
Therapy/modalities billing rule: therapy services and modalities (e.g., 97140, 97010, 97012, 97039) may be billed once per day, per patient and must be performed in conjunction with spinal manipulation services when billed under this enhanced benefit.
X-ray rules: X-rays of the area of chief complaint may be taken at the start of treatment; X-rays of other areas require documentation of medical necessity.
Emergency treatment: emergency treatment of an acute spinal condition must be provided within 48 hours of the injury; follow-up services are payable only if the injury results in an ongoing acute or chronic condition.
Reimbursement: payment will be the lesser of Medicare’s allowed amount or the provider’s charge, minus the member’s cost share; this represents payment in full and providers are not allowed to balance bill members for the difference.
Eligible provider and payable location: Chiropractor; payable location = office.
Member cost sharing and billing: providers should collect applicable Medicare Plus Blue cost sharing at time of service when possible; providers must follow applicable BCBSM reimbursement and billing rules and may not require members to sign an ABN to shift liability for noncovered services under this policy framework.
Applicability: This enhanced benefit applies only to select Medicare Plus Blue Group PPO plans that include the chiropractic enhancement and does not apply to Medicare Plus Blue PPO individual members; group determines specific cost sharing and frequency limits.