Modifiedblue cross blue shield - michiganPolicy N/A

Chiropractic Care

Defines coverage, payment, billing, and frequency limits for chiropractic care and related diagnostic x-rays and visits for BCN Advantage Medicare Advantage members and select group plans.

Policy Summary

Payerblue cross blue shield - michigan

PolicyChiropractic Care

Policy CodePolicy N/A

Change TypeAdded CPT codestemplate revision

Effective Date01/01/2026

Next Review DateN/A

Key ActionVerify benefits and cost-share via provider portal or phone prior to service and submit claims on CMS 1500 using BCN Advantage billing requirements and NPI.

SourceLink

POLICY UPDATE CHANGES

Physical therapy CPT codes 97012, 97110, 97112, 97140 and 97530 were added retroactively effective 01/01/2026.

Policy template was transitioned to a new template on 01/01/2026.

1diagnostic X-ray set covered annually

36 monew patient visit frequency

12 moestablished patient visit frequency

5PT codes added

01/01/2026

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.

Coverage Criteria

Chiropractic coverage criteria

Enhanced chiropractic coverage for BCN Advantage members supplements Original Medicare with specified diagnostic x-ray and visit allowances, frequency limits, and reimbursement protections. Covered when ALL of the following apply:

Enhanced benefit applies to BCN Advantage members and select group plans that include this benefit (supplements Original Medicare).

ALL of the following

One set of diagnostic X-rays (up to three views) of the area of chief complaint is covered once annually; X‑rays of areas other than the area of chief complaint require documentation showing medical necessity.

ALL of the following

New patient visits (CPT 99202, 99203) payable once every 36 months per chiropractor.
Established patient visits (CPT 99212, 99213, 99214) payable once every 12 months per chiropractor.

ALL of the following

Original Medicare coverage is limited to manual spinal manipulation to correct a subluxation; manipulative services must be reasonable, necessary, and directly related to the condition.
For Medicare purposes, modifier AT must be placed on claims for active/corrective treatment; maintenance therapy is not covered by Medicare and claims without modifier AT are considered maintenance and denied.

ALL of the following

Report office visit and x‑ray CPT/HCPCS codes to highest specificity; applicable codes for the enhanced chiropractic benefit include the listed spine x‑ray codes and office visit codes (see coding table). University of Michigan MA only: PT codes 97012, 97110, 97112, 97140, 97530 are applicable.

ALL of the following

BCN Advantage pays the lesser of Medicare's allowed amount or the provider's charge minus the member's cost share; providers may not balance bill members.
Providers should collect applicable member cost share at time of service per BCN/group determinations; the enhanced benefit does not override member benefit documents.

ALL of the following

Bill services on the CMS 1500 form using BCN Advantage billing requirements and include provider NPI; follow BCBSM/BCN provider manual instructions for claim submission.

ALL of the following

Medicare carriers/MACs may require medical documentation or chart review after certain numerical or dollar thresholds; providers may be required to submit supporting documentation for billed claims, especially if non‑contracted.

ALL of the following

Enhanced coverage does not change Medicare's definition of medically necessary services; this Enhanced Benefit Policy is not an authorization or guarantee of payment and does not replace clinical judgment.

Frequency note

Visit and x‑ray frequency limits apply per chiropractor as specified above.

Coverage criteria and notes

Coverage decisions reference Medicare guidance and internal BCBSM/BCN policies; providers must consult member benefit documents and applicable provider manuals for final coverage determinations.

ALL of the following

Policy references Medicare Benefit Policy Manual Chapter 15 (Coverage of Chiropractic Services), Medicare Claims Processing Manual Chapter 12 (Chiropractic Services), and Medicare.gov coverage information.

ALL of the following

CPT codes 97012, 97110, 97112, 97140, and 97530 were added retroactively effective 01/01/2026 (University of Michigan MA only) as documented in policy history.

ALL of the following

Providers must review applicable BCBSM reimbursement policies prior to claim submission and follow the provider manual; contracted providers should follow network requirements and non‑contracted providers may be required to submit supporting documentation and medical records.

Coding and Billing Codes

Applicable CPT/HCPCS codes for enhanced chiropractic benefitCPTCovered

72020	Radiologic examination, spine, single view, specify level
72040	Radiologic examination, spine, cervical; 2 or 3 views
72050	Radiologic examination, spine, cervical; 4 or 5 views
72052	Radiologic examination, spine, cervical; 6 or more views
72070	Radiologic examination, spine; thoracic, 2 views
72072	Radiologic examination, spine; thoracic, 3 views
72100	Radiologic examination, spine, lumbosacral; 2 or 3 views
97012	Therapeutic procedure, therapeutic exercises, each 15 minutes

Physical therapy CPT codes addedCPTCovered

97012	Physical therapy modality; traction, mechanical
97110	Therapeutic exercises
97112	Neuromuscular re-education
97140	Manual therapy techniques, each 15 minutes
97530	Therapeutic activities

Medicare carrier documentation trigger — inv-05: Medicare carrier documentation trigger (note)

Medicare carrier/MAC review triggerMedicare carriers or A/B Medicare Administrative Contractors may require medical documentation or chart review after certain numerical or dollar thresholds before paying billed chiropractic services.

No fixed Medicare dollar capsOriginal Medicare does not impose specific caps or dollar value limits for covered chiropractic care; triggers are carrier/MAC-determined.

Implication for providersIf care exceeds local carrier or MAC thresholds, providers should be prepared to supply supporting medical documentation or chart notes upon request.

Provider Actions and Billing Requirements

Billing Rule

Pre-service verification and billing submission

Verify member benefits, prior authorization and cost-share before providing services. Submit claims on the CMS 1500 (02/12) form and follow BCN Advantage unique billing requirements. Report CPT/HCPCS and diagnosis codes to the highest level of specificity and include your NPI on all claims. Use electronic billing when possible and send paper claims to the BCN Advantage Claims address for paper submission.

Bill services on the CMS 1500 (02/12) claim form.
Use BCN Advantage unique billing requirements.
Report CPT/HCPCS and diagnosis codes to the highest level of specificity.
Include National Provider Identifier (NPI) on all claims.
Send electronic and paper claims to BCN Advantage.
Electronic billing resources for Michigan providers: ANSI ASC X12N 837 and 835 guidance at bcbsm.com/providers/help/edi/.
Paper claims mailing address: BCN Advantage Claims, Blue Care Network, P.O. Box 68753, Grand Rapids, MI 49516-8753.

Definitions

inv-09: Chiropractic care — definition and common treatment (spinal manipulation)

DefinitionChiropractic care focuses on disorders of the musculoskeletal and nervous systems and the effects of these disorders on general health, most often treating neuromusculoskeletal complaints such as back pain, neck pain, headaches, and joint pain.

Common therapeutic procedureThe most common procedure performed by doctors of chiropractic medicine is spinal manipulation (manual adjustment) to restore joint mobility and alleviate pain.

ApproachChiropractors use a drug-free, hands-on approach including patient examination, diagnosis, and treatment.

inv-10: Maintenance therapy (Medicare definition)

Medicare definitionMaintenance therapy refers to services that seek to prevent disease, promote health, prolong or enhance quality of life, or maintain or prevent deterioration of a chronic condition when further clinical improvement cannot reasonably be expected.

Policy Summary

Payerblue cross blue shield - michigan

PolicyChiropractic Care

Policy CodePolicy N/A

Change TypeAdded CPT codestemplate revision

Effective Date01/01/2026

Next Review DateN/A

Key ActionVerify benefits and cost-share via provider portal or phone prior to service and submit claims on CMS 1500 using BCN Advantage billing requirements and NPI.

SourceLink

On This Page

ALL of the following

This Enhanced Benefit Policy is not an authorization, certification, explanation of benefits, or a contract and does not guarantee payment; it does not replace independent medical judgment.

ALL of the following

Medicare carriers or MACs may require medical documentation or chart review after specified numerical or dollar thresholds; providers should be prepared to supply documentation when requested.

ALL of the following

Individual member benefit plan documents (Evidence of Coverage, Annual Notice of Change) and applicable laws govern final coverage, inclusions, exclusions, and restrictions.

Operational note

Providers should verify member eligibility and benefit details (including cost share and whether the enhanced chiropractic benefit is included) via BCN provider portal or by phone prior to providing services.

Documentation Required

Potential documentation triggers

Medicare carriers and A/B Medicare Administrative Contractors may require medical documentation or chart review after certain numerical or dollar thresholds are reached. Original Medicare does not set specific caps for chiropractic care, but local contractors may apply review limits that can trigger documentation requests prior to payment.

Potential post-payment or pre-payment documentation triggers may be based on numerical service counts or total billed dollar amounts.
Providers should be prepared to supply medical records or chart documentation if contacted by Medicare carriers or MACs.
Review local Medicare carrier / MAC guidance for any specific thresholds or review policies.

Documentation Required

Provider documentation and claim submission

Review applicable BCBSM/BCN reimbursement and Medicare Advantage policies before submitting claims. Follow the BCBSM/BCN provider manual for any additional claim-submission requirements. Providers not contracted with BCBSM/BCN Medicare Advantage networks may be required to submit supporting documentation for billed claims. Do not balance-bill members when prohibited by contract or plan documents.

All providers must review BCBSM reimbursement policies prior to claim submission.
Contracted providers should follow provider manual claim-submission requirements.
Non-contracted providers may need to submit medical records to support billed services.
Avoid balance billing when the member's plan or contract prohibits it.
Enhanced Benefit Policies are not authorizations or guarantees of payment; verify coverage via member benefit documents (Evidence of Coverage, Annual Notice of Change) and applicable law.

Coverage implicationOriginal Medicare will not pay for maintenance therapy; claims without modifier AT are considered maintenance therapy and denied.

Modifier guidanceFor Medicare purposes, modifier AT (acute treatment) must be placed on the claim when providing active or corrective treatment; it must not be placed when maintenance therapy has been provided.

inv-11: Medicare Advantage Enhanced Benefit Policy — definition/label

Policy labelMedicare Advantage Enhanced Benefit Policy — the term used in this document to describe BCN/BCBSM policies that specify criteria for services when Medicare rules are not fully developed.

PurposeThese Enhanced Benefit Policies list the criteria BCBSM and BCN use to decide which medical services are considered 'reasonable and necessary' for Medicare Advantage members.

LimitationsEnhanced Benefit Policies are not authorizations, guarantees of payment, or replacements for provider clinical judgment; providers must still follow member benefit documents and provider manual requirements.

inv-12: Non-discrimination statement — obligations under Section 1557 and Section 504

Non-discrimination commitmentPursuant to Section 1557 and Section 504, Blue Cross does not discriminate on the basis of race, color, national origin, age, disability, or sex (including sex characteristics, pregnancy, sexual orientation, and gender identity).

ScopeThis non-discrimination obligation applies to rules, benefit designs, and medical policies described in the Enhanced Benefit Policy.

Provider responsibilityProviders should be aware that Enhanced Benefit Policies and related benefit designs must comply with federal non-discrimination requirements and applicable laws.