CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Chiropractic Services Payment Policy 01.01.23

Defines billing, coverage limits, coding, documentation, and medical necessity requirements for chiropractic services for Neighborhood Health Plan of Rhode Island members (Commercial and INTEGRITY). Applies to licensed chiropractors and those with physiotherapy license where specified.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChiropractic Services Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeAnnual review — no content changes

Effective DateJan 1, 2023

Next Review Date

Key ActionMaintain documentation supporting services billed and medical necessity; Neighborhood may request records and follows CMS documentation standards

SourceLink

POLICY UPDATE CHANGES

01/01/2023 Annual Policy Review Date. No content changes.

11/09/2021 Policy Created

12Commercial visit limit per plan year

1Treatments allowed per day

3Primary CMT CPT codes listed

30+Additional CPT/HCPCS codes listed for physiotherapy-qualified chiropractors

Policy summary

Overview: Chiropractic services focus on disorders of the musculoskeletal and nervous systems using manipulation, adjustment, physiotherapy, and support devices and are intended to treat musculoskeletal complaints. Coverage applies to licensed chiropractors (and chiropractors with a physiotherapy license for additional modalities) for Neighborhood Health Plan of Rhode Island members under Commercial and INTEGRITY product lines. Services must be medically necessary, with providers responsible for verifying eligibility, coverage, and authorization prior to rendering services and maintaining documentation that supports billed services and medical necessity. For INTEGRITY there is no annual visit limit but treatment is limited to not more than one treatment per day; for Commercial the chiropractic benefit is limited to twelve (12) visits per plan year. X‑rays or other diagnostic procedures ordered, taken, or interpreted by a chiropractor may be used for documentation only and are not covered or payable. Effective date/status: Effective 2023-01-01; policy status CURRENT (Annual Policy Review 01/01/2023, no content changes; original policy created 11/09/2021).

Key summary facts

Commercial visit limit per plan year12

Treatments allowed per day1

Primary CMT CPT codes listed98940, 98941, 98942 (3 codes)

Additional CPT/HCPCS codes for physiotherapy-qualified chiropractors30+ codes (e.g., 97010, 97012, 97014, 97016, 97018, ...)

Effective Date2023-01-01

Last Review2023-01-01

Policy StatusCURRENT

Code lists

Chiropractor spinal manipulation CMT codes (approved)CPTCovered

98940	Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
98941	Chiropractic manipulative treatment (CMT); spinal, 3-4 regions
98942	Chiropractic manipulative treatment (CMT); spinal, 5 regions

Additional approved codes for chiropractors with physiotherapy licensemixedCovered

97010	Application of a modality to 1 or more areas; hot or cold packs
97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy (eg, microwave)
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual), each 15 minutes

1–10 of 31

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Billing, documentation and operational requirements

Documentation Required

Medical record documentation

Maintain documentation supporting services billed and medical necessity; Neighborhood may request records and follows CMS documentation standards

Billing Rule

One treatment per day rule

Limit billing to not more than one treatment per day; reimbursement will be limited accordingly

Medicare reimbursement is similarly limited and applies to INTEGRITY

Billing Rule

Commercial visit limit

For Commercial members, limit chiropractic visits to twelve (12) visits per plan year

Billing Rule

X-ray/diagnostic billing restriction

Do not bill Neighborhood for x-rays or other diagnostic/therapeutic services ordered, taken, or interpreted by chiropractors (may be used for documentation only)

Documentation Required

Eligibility and prior authorization verification

Verify member eligibility, coverage and prior authorization criteria prior to rendering services and refer to plan-specific Prior Authorization Reference page

Billing Rule

Timely filing

Submit complete claims within contractually determined timely filing guidelines

Definitions

Maintenance TherapyServices that seek to prevent disease, promote health and prolong and enhance quality of life, or maintain or prevent deterioration of a chronic condition; when further clinical improvement cannot reasonably be expected and care is supportive rather than corrective, it is considered maintenance therapy and is not covered.

Intensive Care (concept)Approach with multiple daily visits (as many as four or five) with room/ward fees charged; room/ward fees are not covered and Medicare reimbursement limited to not more than one treatment per day.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChiropractic Services Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeAnnual review — no content changes

Effective DateJan 1, 2023

Next Review Date

Key ActionMaintain documentation supporting services billed and medical necessity; Neighborhood may request records and follows CMS documentation standards

SourceLink

On This Page

OpenPayer

Chiropractic Services Payment Policy 01.01.23

Policy summary

Medical necessity and coverage criteria

Exclusions / Not covered

Code lists

Billing, documentation and operational requirements

Definitions

Policy change log