CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP016

Chiropractic Care Services (CPCP016)

This policy defines billing, documentation, coding, and medical necessity standards for chiropractic care services provided to Blue Cross Blue Shield New Mexico members and governs provider reimbursement and claim adjudication.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyChiropractic Care Services (CPCP016)

Policy CodePolicy CPCP016

Change TypeNo material changes

Effective DateMar 22, 2023

Next Review DateN/A

Key ActionSubmit accurate supporting documentation upon request; claims are subject to review and documentation may be required to support billed chiropractic services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

98940-98943Primary CMT codes referenced

99202-99205;99211-99215E/M codes discussed

≤90 daysTreatment plan max interval

SOAPRequired documentation

03/15/2023Structural update

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.

Medical necessity, documentation, billing and exclusions for chiropractic services

Covered when ALL of the following licensure, medical necessity, documentation, and billing requirements are met. Maintenance care and supportive care are excluded.

ALL of the following

ALL of the following
- Provider must be licensed and act within scope of licensure to bill for chiropractic services.
ALL of the following
- Each CMT billed must have a supporting ICD-10-CM diagnosis that justifies the number of regions billed (eg, CPT 98941 requires ICD-10-CM codes that incorporate at least three different regions).
- Each manipulation reported must relate to a relevant symptomatic spinal or extraspinal level; documentation must state location of pain/condition, specific spinal regions adjusted, and technique used.
ALL of the following
- Records must indicate dates of service, list direct one-on-one contact time for each timed code, be legible, and use comprehensible terms/abbreviations.
- Clinical record content: include clinically pertinent subjective information (chief complaint, changes since last visit, response to care), objective examination findings to verify diagnosis, and assessment of progress with rationale for continued care or change in direction.
- Progress notes and treatment details: document the treatment performed during the visit, medical rationale, member instructions, immediate response to care, anticipated return/visit number and next evaluation date, goals and outcome measures.
- Treatment plan requirements: a written plan must document type, amount, frequency, duration, goals, objective measures and rationale; the plan must be updated as condition changes and is not valid beyond 90 days from the first treatment day under the certified plan.
ALL of the following
- CMT and E/M interaction
  - Do not routinely bill an established outpatient E/M (99211-99215) on the same day as CMT (98940-98943); an E/M may be appropriate for new patients, new injuries, exacerbations, or periodic re-evaluations.
  - It is not appropriate to bill an E/M in place of a CMT to circumvent CMT limits; bill the code that best describes the service rendered.
- Provider billing responsibility: chiropractors may not bill for CMT, constant-attendance modalities, or therapeutic procedures unless the services were directly performed by the chiropractor.
ALL of the following
- Maintenance Care and Supportive Care (ongoing treatment after therapeutic goals are achieved or when no further functional progress is expected) are not medically necessary and are not payable.
ALL of the following
- Diagnosis reported on the claim (Box 24E) must reflect the condition being managed and be updated for each new episode or re-exam.
- Diagnostic imaging and other testing must be clinically indicated, of diagnostic quality, interpreted with documented findings and correlated with patient management; routine screening radiography is not appropriate.

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title

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CPT and E/M Codes, Code-Specific Rules

CMT codesCPTCovered

98940-98943

Chiropractic Manipulative Treatment (CMT) codes by number of regions treated

E/M codesCPT

99202-99205, 99211-99215

Evaluation and Management (E/M) services — billable when complete CPT guidelines are met and the service is separately identifiable and distinct from other services performed the same day

Regions required for CPT 98941

Requirement for CPT 98941CPT 98941 requires supporting ICD-10-CM diagnosis codes that incorporate at least three different regions to justify billing this code.

CPT code regional ruleEach CMT CPT code reflects a specific number of regions regardless of number of manipulations; e.g., manipulations at C3 and C5 are a single cervical region and billed as 98940.

Documentation linkageAll CMT codes must have an ICD-10-CM diagnosis code that justifies the level of care provided.

CMT component count

Component structureCMT is described as three components: Pre-Service (1), Intra-Service (1), and Post-Service (1).

Pre-Service detailsPre-Service includes brief evaluation of records, chart review, imaging review, test interpretation, and care planning.

Intra-Service detailsIntra-Service includes treatment applied, pre-manipulation (e.g., palpation), manipulation, and post-manipulation assessment.

Post-Service detailsPost-Service includes chart entry and documentation, including subjective, objective, assessment, plan, and consultation reporting.

Billing Responsibilities and Documentation Requests

Documentation Required

Documentation upon request and claim review

Providers are responsible for submission of accurate documentation of services performed and are expected to submit claims using valid HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, DRG, etc.) and industry coding guidelines (AMA CPT, CMS NCCI/CCI edits, UB Editor, CPT Assistant). Claims are subject to code edit protocols and claim review for benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request and/or during claim review, the plan reserves the right to request supporting documentation; providers are urged to submit any additional documentation to substantiate services billed.

Include clinical records, operative notes, test results, treatment plans, and any other documentation supporting medical necessity and coding.
Maintain documentation in accordance with payer and regulatory requirements and make records available upon request for medical review or audit.

Billing Rule

Provider billing responsibility

Providers must bill and document appropriately for all services submitted. Failure to adhere to coding and billing policies may impact claims processing and reimbursement. Claims may be reviewed on a case‑by‑case basis; the plan reserves the right to request supporting documentation. Contact your provider network representative with questions.

Chiropractors may not bill for chiropractic manipulative treatment, constant attendance modalities, or therapeutic procedures unless directly performed by the chiropractor.
Use valid code combinations and follow applicable coding guides (CPT®, HCPCS, ICD‑10, NDC, DRG, CMS NCCI/CCI).

Key Definitions

Chiropractic Manipulative Treatment (CMT)

DefinitionChiropractic Manipulative Treatment (CMT) uses high-velocity, short-lever, low-amplitude thrust by hand or instrument to address structural dysfunction in joints and muscles; categorized as spinal or extraspinal.

Spinal vs ExtraspinalSpinal CMT: cervical, thoracic, lumbar, sacral, and pelvic regions; Extraspinal CMT: manipulative treatment of the appendicular skeleton.

Documentation requiredFor CMT, documentation must state location of pain, specific spinal regions adjusted, technique used, response to treatment, and that each manipulation relates to a symptomatic level.

Chiropractic Maintenance Care

DefinitionMaintenance Care consists of activities that preserve the patient's present level of function and prevent regression after therapeutic goals are achieved or no further functional progress is expected.

Clinical plateauOngoing treatment after a condition has been stabilized or reached Maximum Therapeutic Benefit is considered maintenance care.

Payment stanceMaintenance Care and Supportive Care are not medically reasonable or necessary and are NOT payable.

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 service.

Scope and supervisionProviders of chiropractic services must act within the scope of their license; nonqualified personnel are limited to non-skilled services and may not bill direct treatments or procedures.

Billing limitationServices billed by the chiropractor that are provided by others must comply with state board regulations governing scope and extent of those services.

Initial Treatment Date (ITD)

DefinitionInitial Treatment Date (ITD): the date of the initial treatment (visit) entered in Box 15 (other date) of the CMS-1500 claim form.

Use on claimsEnter the ITD in Box 15 of the CMS-1500 to indicate the first treatment visit for the episode of care.

Relation to documentationITD should align with clinical records documenting the initial visit and treatment provided.

Date of Injury (DOI)

DefinitionDate of Injury (DOI): the actual date of the current injury, entered in Box 14 of the CMS-1500 claim form.

Claim reportingEnter the DOI in Box 14 of the CMS-1500 to reflect when the injury occurred.

Clinical linkageDOI should correspond to documentation of the incident or clinical history in the medical record.

OpenPayer

Chiropractic Care Services (CPCP016)

Coverage, Medical Necessity, Documentation, and Exclusions

CPT and E/M Codes, Code-Specific Rules

Billing Responsibilities and Documentation Requests

Key Definitions