CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP016

Chiropractic Care Services

Defines billing, documentation, coding, and medical necessity standards for chiropractic manipulative treatment and related chiropractic services for Blue Cross Blue Shield - Oklahoma members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyChiropractic Care Services

Policy CodePolicy CPCP016

Change TypeNo material changes

Effective DateJan 25, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide supporting documentation; chiropractors may not bill for CMT or modalities unless directly performed by the chiropractor.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 98940-98943Primary CMT codes referenced

99202-99205, 99211-99215E/M codes discussed relative to CMT

90 daysTreatment plan max validity

Documentation standardsRequired medical record elements

CPCP016Document ID

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Coding and Treatment Plan Rules

Chiropractic Manipulative Treatment (CMT)CPT

98940-98943

Chiropractic Manipulative Treatment (CMT) by region

Evaluation and Management (E/M) ServicesCPT

99202-99205, 99211-99215

Evaluation and Management (E/M) services

Treatment Plan Validity

Maximum validityA treatment plan is not valid for longer than 90 calendar days from the first treatment day under the certified treatment plan.

Required elementsWritten plan must state type, amount, frequency, duration of care, specific treatment goals with anticipated time frames and objective measures, and rationale for services.

UpdatesThe plan of care must be updated as the member's condition changes and include anticipated date of next evaluation and visit number relative to the treatment plan.

Documentation and Billing Responsibility

Documentation Required

Documentation, billing accuracy, and chiropractic billing restriction

Providers are responsible for submitting accurate documentation of services performed and must bill using valid HIPAA-approved code sets; the plan may request supporting documentation and review claims against coding, contracts, and policy terms. Chiropractors may not bill for chiropractic manipulative treatment, constant attendance modalities, or therapeutic procedures unless those services were directly performed by the chiropractor.

Submit claims using valid HIPAA-approved code sets (CPT®, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, etc.).
Be prepared to provide additional supporting documentation upon request; failure to adhere may affect claims processing and reimbursement.
Chiropractors may only bill for CMT, constant attendance modalities, or therapeutic procedures when directly performed by the chiropractor.

Key Definitions

Chiropractic Manipulative Treatment (CMT) Definition

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

ScopeIncludes spinal (cervical, thoracic, lumbar, sacral, pelvic) and extraspinal (appendicular skeleton) manipulative treatments.

PurposePerformed to address structural dysfunction that may be associated with neurologic or mechanical dysfunction of spinal joints and surrounding tissue.

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 when no further functional progress is expected.

Clinical plateauOngoing treatment after a condition has stabilized or reached maximum therapeutic benefit is maintenance care and not medically necessary.

Payment stanceMaintenance care and supportive care are not medically reasonable or necessary and are NOT payable.

Qualified Healthcare Professional (QHP)

DefinitionQualified Healthcare Professional (QHP) is 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.

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

Credentials requiredActive license, certification, or registration with the applicable state board or agency is required to provide services under a chiropractor's treatment plan.

Initial Treatment Date (ITD)

DefinitionInitial Treatment Date (ITD) is the date of the initial treatment (visit).

Claim form referenceEnter the ITD in Box 15 (other date) of the CMS-1500 claim form.

UseITD documents the starting point of the certified treatment plan and visit counting for the plan of care.

Date of Injury (DOI)

DefinitionDate of Injury (DOI) is the actual date of the current injury.

Claim form referenceEnter the DOI in Box 14 of the CMS-1500 claim form.

PurposeDOI links the clinical condition to the date of onset for documentation and billing purposes.