Chiropractic Guide — Claim Processing and Benefit Overview
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Guidance on claim submission, coverage limits, modifiers, prior authorization references, and billing rules for chiropractic services for i Care members (Medicare and Medicaid). Affects providers billing chiropractic services to Integrated Home Care Services (i Care).
No material clinical or coverage changes in this revision.
Chiropractic Coverage Rules
Chiropractic coverage criteria
Covered when ALL of the following conditions are met:
Medicare-specific limitation applies to i Care Medicare members.
Required diagnosis for Medicaid reimbursement.
See payer prior authorization list for other procedures that may require PA.
Per-date-of-service limit for all applicable members.
Modifier requirement for Medicare claims.
Diagnosis, Procedure Codes, and Modifiers
| 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 |
| AT | Anesthesia modifier required for Standard Benefits (per document) |
| CE | Do NOT use CE modifier (Enhanced Benefits Ended) |
Prior Authorization & Provider Requirements
Prior Authorization reference
Refer to the procedure-specific Prior Authorization list on the iCare provider website to determine whether the services you plan to provide require prior authorization. Access the list at the iCare Provider page under Prior Authorizations.
- Website: https://www.icarehealthplan.org/Provider.htm (Providers > Prior Authorizations)
Medicaid PA exemption for initial/manipulations
For Medicaid members, the initial visit and the first 20 spinal manipulations do not require prior authorization.
- Medicaid reimburses manual spinal manipulations only for a diagnosis of subluxation; manipulations for strains and sprains are not covered.
- Only one spinal adjustment per date of service per member is reimbursable.
Service Definitions & Medicaid/Medicare Limits
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