CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Chiropractic services coverage (Chiropractic Manipulative Treatment)

Defines coverage, coding, and administrative rules for chiropractic manipulative treatment and related services for Blue Cross Blue Shield of Rhode Island members, including distinctions for Commercial and Medicare Advantage products and place-of-service limits.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyChiropractic services coverage (Chiropractic Manipulative Treatment)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member-specific benefits with the provider call center before assuming coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CMT CPT codes listed (98940-98942)

6Covered diagnosis codes (M99.00-M99.05)

office-onlyPlace of service restriction

daily maxCommercial products daily max

~60+Procedure/supply codes listed

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Coverage Criteria for Chiropractic Services

Chiropractic Manipulative Treatment

Covered when ALL of the following are met:

CMT coding and diagnosis: CMT billed with CPT codes 98940-98942 (98943 is listed but is non-covered for Medicare Advantage Plans) AND billed with a covered diagnosis code M99.00-M99.05

Commercial product reimbursement

Commercial product coverage specifics:

Daily maximum inclusion: For Commercial products, listed chiropractic (CPT 98940-98943), E/M (CPT 99202-99205, 99211-99215), modality (CPT 97012-97036), therapeutic procedure (CPT 97110-97530), orthotic management (CPT 97760, 97761, 97763) and test/measurement codes (CPT 97750-97755) are included in the daily maximum reimbursement rate for participating providers

Laboratory procedures, radiological examinations and durable medical equipment codes listed separately are not part of the daily maximum and may be reimbursed separately

Place of Service

Place of service restriction:

Allowed settings: Chiropractic services are limited to office settings and are not covered when performed in the home, nursing, residential, domiciliary, or custodial facility for all BCBSRI products including Medicare Advantage Plans

General Coverage Conditions

Coverage contingent on member benefits and medical necessity determinations

Governing conditions: Services are subject to the member's subscriber agreement/member certificate and employer agreement; payment is contingent on medical necessity determinations

Verify member-specific benefits with the provider call center

For Medicare Advantage plans, chiropractic coverage is limited to spinal manual manipulation (Chiropractic Manipulative Treatment, CMT) billed with the designated CMT CPT codes. The policy explicitly states that CPT code 98943 (extra‑spinal) is not covered for Medicare Advantage members; covered spinal CMT codes are 98940–98942. [[chunk 13]]

Services that are determined to be not medically necessary or that qualify as non‑covered benefits under the member’s plan are excluded from payment. Providers should verify member‑specific benefits via the provider call center and may not charge members for services found to be not medically necessary unless the member has been informed and has provided a written agreement in advance. [[chunk 23]]

Medicare Advantage plans restrict chiropractic coverage to spinal manual manipulation only. The policy states that all other chiropractic‑related services beyond spinal CMT are limited under Medicare Advantage and therefore are not covered. Additionally, Medicare Advantage does not allow chiropractic providers to order, perform, or interpret X‑rays or diagnostic tests. Providers who believe a service will not be covered must request a pre‑service organization determination; failing to do so may make the provider financially liable. [[chunk 3]][[chunk 4]][[chunk 13]]

If services are determined to be not medically necessary or to be non‑covered benefits, payment may be denied. The policy requires providers to confirm benefits and eligibility per the member’s subscriber agreement or certificate, and warns that providers may not bill members for such services unless the member has been informed and has signed a prior written agreement. Providers should use the provider call center to verify member‑specific coverage before rendering services that may be in question. [[chunk 23]][[chunk 4]]

Coding, Reimbursement, and Limits

Covered CPT Codes - Chiropractic Manipulation TreatmentCPTCovered

98940	Chiropractic manipulative treatment (CMT); spinal, one to two regions
98941	Chiropractic manipulative treatment (CMT); spinal, three to four regions
98942	Chiropractic manipulative treatment (CMT); spinal, five regions
98943	Chiropractic manipulative treatment (CMT); extra-spinal, one or more regions (non-covered for Medicare Advantage Plans)

Covered CPT Codes - Evaluation and ManagementCPTCovered

99202	Office or other outpatient visit for the evaluation and management of a new patient; 15-29 minutes
99203	Office or other outpatient visit for the evaluation and management of a new patient; 30-44 minutes
99204	Office or other outpatient visit for the evaluation and management of a new patient; 45-59 minutes
99205	Office or other outpatient visit for the evaluation and management of a new patient; 60-74 minutes
99211	Office or other outpatient visit for the evaluation and management of an established patient; may not require presence of physician
99212	Office or other outpatient visit for the evaluation and management of an established patient; 10-19 minutes
99213	Office or other outpatient visit for the evaluation and management of an established patient; 20-29 minutes
99214	Office or other outpatient visit for the evaluation and management of an established patient; 30-39 minutes
99215	Office or other outpatient visit for the evaluation and management of an established patient; 40-54 minutes

Covered CPT Codes - Physical Medicine / Therapy and Test CodesCPTCovered

97012	Application of a modality to one or more areas; traction, mechanical
97014	Application of a modality to one or more areas; electrical stimulation (unattended)
97016	Application of a modality to one or more areas; vasopneumatic devices
97018	Application of a modality to one or more areas; paraffin bath
97022	Application of a modality; whirlpool
97024	Application of a modality; diathermy
97026	Application of a modality; infrared
97028	Application of a modality; ultraviolet
97032	Application of a modality; electrical stimulation (manual), each 15 minutes
97033	Application of a modality; iontophoresis, each 15 minutes

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Covered CPT Codes - Evaluation and ManagementCPTCovered

99201	New patient code (deleted 12/31/2020)
99202	Office or other outpatient visit for the evaluation and management of a new patient; 15-29 minutes
99203	Office or other outpatient visit for the evaluation and management of a new patient; 30-44 minutes
99204	Office or other outpatient visit for the evaluation and management of a new patient; 45-59 minutes
99205	Office or other outpatient visit for the evaluation and management of a new patient; 60-74 minutes
99211	Office or other outpatient visit for the evaluation and management of an established patient
99212	Office or other outpatient visit for the evaluation and management of an established patient; 10-19 minutes
99213	Office or other outpatient visit for the evaluation and management of an established patient; 20-29 minutes
99214	Office or other outpatient visit for the evaluation and management of an established patient; 30-39 minutes
99215	Office or other outpatient visit for the evaluation and management of an established patient; 40-54 minutes

Covered CPT Codes - Physical Medicine / Therapy and Test CodesCPTCovered

97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual), each 15 minutes
97033	Iontophoresis, each 15 minutes

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Diagnostic Imaging CPT Codes (separately reimbursed)CPTCovered

71045	Radiologic examination, chest; single view
71046	Radiologic examination, chest; 2 views
71047	Radiologic examination, chest; 3 views
71048	Radiologic examination, chest; 4 or more views
72020	Radiologic examination, spine, single view
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

Covered diagnosis codesICD-10Covered

M99.00	Segmental and somatic dysfunction of head region
M99.01	Segmental and somatic dysfunction of cervical region
M99.02	Segmental and somatic dysfunction of thoracic region
M99.03	Segmental and somatic dysfunction of lumbar region
M99.04	Segmental and somatic dysfunction of sacral region
M99.05	Segmental and somatic dysfunction of pelvic region

Evaluation and Therapy CPT CodesCPTCovered

97140	Manual techniques (mobilization/manipulation), each 15 minutes
97150	Therapeutic procedure(s), group (2 or more individuals)
97530	Therapeutic activities, direct (one-on-one), each 15 minutes
97750	Physical performance test/measurement; each 15 minutes
97755	Assistive technology assessment; each 15 minutes
97760	Orthotic management and training, upper extremity; each 15 minutes
97761	Orthotic management and training, lower extremity; each 15 minutes
97763	Orthotic management and training, trunk; each 15 minutes

Diagnostic Imaging CPT Codes (separately reimbursed for Commercial products)CPTCovered

72100	Radiologic examination, lumbosacral; 2 or 3 views
72110	Radiologic examination, lumbosacral; minimum of 4 views
72114	Radiologic examination, lumbosacral; complete, including bending views, minimum of 6 views
72170	Radiologic examination, pelvis; 1 or 2 views
72190	Radiologic examination, complete, minimum of 3 views pelvis
72200	Radiologic examination, sacroiliac joints; less than 3 views
73010	Radiologic examination, shoulder; 1 view
73020	Radiologic examination; acromioclavicular joints, bilateral

Supplies Allowed to be Dispensed by Chiropractors (Commercial products only)HCPCSCovered

E0720	Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0730	Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation
A4595	Supplies related to TENS (as applicable)
E0860	Traction equipment; overdoor, cervical

Daily maximum

Daily maximumChiropractic services are subject to the member's benefit plan limits. Daily maximum rates apply for Commercial products; listed services (CMT, E/M, PM&R modalities and procedures, orthotic management, test and measurement) are included in the daily maximum.

Provider Actions, Billing, and Documentation Requirements

Prior Authorization

Prior Authorization / Pre-service Determination

Prior authorization review is not required for chiropractic services under this policy. However, for Medicare Advantage members, providers must request a pre-service organization determination if they believe a service will not be covered; failure to request a pre-service determination may result in provider liability for the cost of services.

Medicare Advantage: provider must request pre-service organization determination when service may be non-covered; providers remain liable if they do not request pre-service determination.

Note

Verify Member-specific Benefits

Verify member-specific benefits and eligibility prior to rendering services. Benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement; those documents supersede this medical policy. For member-specific benefit questions, contact the Blue Cross Blue Shield of Rhode Island provider call center.

Benefits and eligibility determined by subscriber agreement/member certificate/employer agreement.
Contact provider call center for member-specific benefits and eligibility.

Billing Rule

Visit Counting and Separate Reimbursement

Chiropractic services for Commercial products are subject to daily maximum reimbursement rates for participating providers. All chiropractic services performed on the same date of service count as one visit toward the member's benefit limit. Laboratory procedures, radiological examinations, and durable medical equipment codes listed in the policy are not part of the daily maximum and may be separately reimbursed.

Daily maximum rates apply to participating providers for Commercial products.
All chiropractic services on the same date count as one visit toward benefit limit.
Laboratory, radiology, and DME codes listed are separately reimbursable and not subject to the daily maximum.

Billing Rule

Required Modifiers for E/M and Therapy Codes

When billing certain E/M and therapy CPT codes, include the required discipline modifier to distinguish the service delivery discipline. Claims filed without the required modifier will deny. Examples: GP for services under an outpatient PT plan of care; GO for services under an outpatient OT plan of care.

Required modifiers (examples): GP - outpatient PT plan of care; GO - outpatient OT plan of care.
Claims without the required discipline modifier will deny.

Documentation Required

Written Report Requirements

Some CPT codes (for example, 97750 and 97755) require a written report when performed. For services that specify 'with written report' in the CPT description (such as certain test and measurement procedures and assistive technology/orthotic assessments), include and retain the written report in the medical record and submit documentation upon request.

CPT codes that include 'with written report' (e.g., 97750, 97755) require a written report in the medical record.
Providers must retain and be able to submit written reports for these services upon request.

Denial Risk

Non-medical Necessity Charges and Denials

If a provider performs services determined to be not medically necessary or are non-covered benefits, the provider may not bill the member unless the member was informed in advance and agreed in writing to accept financial responsibility. Refer to your participation agreement for applicable provisions.

Providers may not charge members for non-covered or not-medically-necessary services unless the member provided written agreement in advance.
Refer to participation agreement for detailed provisions.

Definitions and Code Notes

Subluxation definition

TermSubluxation

DefinitionAn incomplete dislocation, off-centering; misalignment; fixation, or abnormal spacing of the vertebrae

Common categoriesChronic (loss of joint mobility); Acute (strains/sprains); Nerve root problems (e.g., pinched nerve)

Clinical significanceAssociated with reduced motion, pain, swelling, muscle spasm, nerve irritation, cartilage damage and loss of normal range of motion

Chiropractic Manipulative Therapy (CMT) definition

TermChiropractic Manipulative Therapy (CMT)

DefinitionAdjustment and manipulation of joint articulation and adjacent tissues, particularly of the spinal column, to restore normal mobility and range of motion

Primary useRestore joint mobility and range of motion due to subluxation or biomechanical dysfunction

Distinct fromOsteopathic Manipulative Treatment (codes 98925-98929) performed by DOs

97750 (Physical performance test) definition

Code97750

DefinitionPhysical performance test or measurement (musculoskeletal, functional capacity), with written report; each 15 minutes

Reporting requirementIncludes a written report as part of the CPT descriptor

Time unitEach 15 minutes

97755 (Assistive technology assessment) definition

Code97755

DefinitionAssistive technology assessment to restore, augment or compensate for existing function, direct one-on-one contact by provider, with written report; each 15 minutes

PurposeOptimize functional tasks and/or maximize environmental accessibility via assistive technology assessment