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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyIndiana Chiropractic Coverage Update | OpenPayer
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    CurrentIndiana Department of InsurancePolicy PROMOD00021

    Chiropractic Services

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    This policy governs coverage, billing, prior authorization, reimbursement limits, and documentation requirements for chiropractic and certain related services provided under the Indiana Health Coverage Programs fee-for-service delivery system. Managed care services are governed by the applicable managed care entity or provider manual.

    Policy Summary
    PayerIndiana Department of Insurance
    PolicyChiropractic Services
    Policy CodePolicy PROMOD00021
    Change TypeScheduled update, Version 8.0
    Effective DateSeptember 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for muscle testing and applicable therapeutic procedures.
    SourceLink
    POLICY UPDATE CHANGES

    The Chiropractic Services - Manipulative Treatment, Physical Medicine and Office Visits section was updated in version 8.0.

    Indiana PathWays for Aging was added to the initial managed care delivery system note.

    Policy text was clarified as part of the scheduled version 8.0 update.

    50 unitsAnnual chiropractic service limit
    5 visitsAnnual office visit limit
    1 series/yearFull-spine X-ray limit

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    50 units
    Related services outside chiropractic unit limit
    Specialty 150Chiropractor specialty requirement

    Chiropractic Coverage and Service Eligibility

    General chiropractic coverage

    Covered when all of the following requirements are met:

    ALL of the following

    • The service is provided under the Indiana Health Coverage Programs fee-for-service delivery system and is allowed under the member's benefit plan.
    • The service is medically necessary and necessitated by a condition-related diagnosis approved for chiropractor billing.
    • The service is a designated reimbursable chiropractic procedure.

    Manipulative treatment, physical medicine, and office visits

    Manipulative treatment, physical medicine, and office visits are covered subject to the following requirements:

    ALL of the following

    • Total chiropractic services do not exceed 50 units per member per calendar year unless additional treatment is authorized based on medical necessity.50 units per member per calendar year
    • Office visits do not exceed five per member per year within the 50-unit limit.5 visits per member per year
    • Any required prior authorization is obtained for muscle testing services, including manual and electrical testing, and for applicable therapeutic procedures.
    • A same-day office visit with manipulation or physical medicine is a significant, separately identifiable evaluation and management service above and beyond the usual associated preservice and postservice work, is supported by medical-record documentation, and is billed with modifier 25.

    Related services covered for chiropractor billing

    The following related services are reimbursable to chiropractors and are not subject to the 50-unit chiropractic service limitation:

    ANY of the following

    • Designated radiology or laboratory services are medically necessary for an approved chiropractor-billing diagnosis; prior authorization is not required.
    • Diabetes self-management training is billed with the appropriate procedure code-modifier combination, ordered in writing by an Indiana-licensed physician or podiatrist, and performed by a chiropractor with specialized diabetes-management training.
    • Community health worker services are performed by a properly certified community health worker employed by an IHCP-enrolled billing provider, rendered under qualifying practitioner supervision, and billed under the supervising practitioner's NPI.

    Noncovered and restricted services

    The following services or billing situations are not reimbursable or are restricted:

    ANY of the following

    • Durable medical equipment or electromyogram testing provided by chiropractors is not reimbursable.
    • New patient detailed, new patient comprehensive, established patient detailed, and established patient comprehensive office visits are not reimbursable to chiropractors.
    • Additional full-spine X-rays beyond one series per member per year are not reimbursable; when component X-rays are billed separately, total reimbursement cannot exceed the allowable amount for the full-spine series.1 full-spine X-ray series per member per year

    Codes, Limits, and Billing Parameters

    Designated chiropractic procedure codesCPTCovered
    No codes listed
    Approved chiropractor diagnosis codesICD-10Covered
    No codes listed
    Modifier for same-day separately identifiable office visitModifierCovered
    25Significant, separately identifiable evaluation and management service
    DSMT procedure code-modifier combinationsmixedCovered
    No codes listed
    Designated community health worker procedure codesmixedCovered
    No codes listed
    DME and EMG testing provided by chiropractorsmixedNot Covered
    No codes listed
    Annual chiropractic service limit
    Annual limit50 units per member per calendar year
    Services includedOffice visits, spinal manipulation, and physical medicine services
    Additional treatmentAdditional treatments may be authorized with prior authorization based on medical necessity
    Annual chiropractic office visit limit
    Annual office visit limitFive visits per member per year
    Relationship to annual limit

    Authorization, Documentation, and Billing Actions

    Prior Authorization

    Prior Authorization for Chiropractic Services

    Prior authorization (PA) is required for muscle testing, including manual and electrical testing, and for certain therapeutic procedures. Providers should consult the Professional Fee Schedule and the applicable criteria in 405 IAC 5-12 to determine whether PA is required for a service.

    • PA applies to both manual and electrical muscle testing.
    • PA requirements for therapeutic procedures vary by service.
    Prior Authorization

    Authorization for Treatment Beyond the Annual Limit

    Chiropractic reimbursement is limited to 50 combined units per member per calendar year, including office visits, spinal manipulation, and physical medicine services. Additional medically necessary treatment may be authorized through PA.

    • No more than five of the 50 annual units may be office visits.
    • For Hoosier Healthwise Package C, coverage is limited to five visits and 14 therapeutic physical medicine treatments annually; approved medical-necessity PA may allow up to 36 additional treatments.

    Policy Terms and Delivery System Definitions

    Significant, separately identifiable E/M service
    Separate from other serviceThe office visit is significant and separately identifiable from the manipulation or physical medicine service
    Additional workThe service must be above and beyond the usual preservice and postservice work associated with manipulation or physical medicine
    Billing requirementReport the office visit with modifier 25
    FFS delivery system
    Covered delivery systemIndiana Health Coverage Programs services provided under the fee-for-service delivery system
    Managed care servicesServices provided through managed care are directed to the member's managed care entity
    Policy Summary
    PayerIndiana Department of Insurance
    PolicyChiropractic Services
    Policy CodePolicy PROMOD00021
    Change TypeScheduled update, Version 8.0
    Effective DateSeptember 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for muscle testing and applicable therapeutic procedures.
    SourceLink
    On This Page
    Chiropractic Coverage and Service EligibilityCodes, Limits, and Billing ParametersAuthorization, Documentation, and Billing ActionsPolicy Terms and Delivery System Definitions
    Up to five of the 50 annual chiropractic units may be office visits
    Prior authorizationPrior authorization is not required for office visits
    Hoosier Healthwise Package C annual limit
    Annual visitsFive visits per year
    Therapeutic physical medicine14 therapeutic physical medicine treatments per year
    Member groupHoosier Healthwise Package C members
    Hoosier Healthwise Package C additional authorized treatments
    Additional treatmentsUp to 36 additional treatments may be covered
    Authorization requirementPrior authorization must be approved
    Basis for approvalApproval is based on medical necessity
    Full-spine X-ray frequency
    Frequency limitOne series of full-spine X-rays per member per year
    Component X-raysComponent X-rays in the series are individually reimbursable
    Reimbursement capWhen components are billed separately, total reimbursement is limited to the allowable amount for the series
    New patient office visit frequency
    Provider lifetime limitOnce per provider during the member's lifetime
    Same specialty and practiceOnce per three-year period for a provider of the same specialty and in the same practice
    Service typeNew patient office visits

    Unsupported block type: info

    Unsupported block type: documentation

    Unsupported block type: billing_rule

    Unsupported block type: billing_rule

    Unsupported block type: billing_rule

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: billing_rule

    Unsupported block type: documentation

    Unsupported block type: documentation

    Reference for managed care billingProviders should refer to the applicable managed care entity provider manual
    Qualifying community health worker
    CertificationThe community health worker meets certification requirements
    EmploymentThe community health worker is employed by an IHCP-enrolled billing provider
    SupervisionThe community health worker renders services under the supervision of a qualifying IHCP-enrolled practitioner