CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Chiropractic Services Payment Policy 12.01.21

Defines billing, coding, coverage limits, and documentation requirements for chiropractic services for Neighborhood Health Plan of Rhode Island commercial and INTEGRITY products. Specifies covered CPT/HCPCS codes, visit limits (commercial), daily limits, and exclusions.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChiropractic Services Payment Policy 12.01.21

Policy CodePolicy N/A

Change TypePolicy Review / Creation (2021)

Effective Date

Next Review Date

Key ActionProviders must bill no more than one chiropractic treatment per member per day; room/ward fees for multiple daily visits are not reimbursed.

SourceLink

POLICY UPDATE CHANGES

11/30/2021 Action = Policy Review

11/09/2021 Action = Policy Created

12Commercial visit limit

1/dayDaily treatment limit

No annual limitINTEGRITY visit limit

Policy overview

Payer: Neighborhood Health Plan of Rhode Island. Policy title: Chiropractic Services Payment Policy — defines billing, coding, coverage limits, and documentation requirements for chiropractic services for Neighborhood's INTEGRITY and Commercial products.

Policy Metadata

PayerNeighborhood Health Plan of Rhode Island

PolicyChiropractic Services Payment Policy

Policy CodeN/A

Effective Date

Last Review2021-11-30

Next Review

StatusCURRENT

Scope SummaryDefines billing, coding, coverage limits, and documentation requirements for chiropractic services for Neighborhood Health Plan of Rhode Island commercial and INTEGRITY products. Specifies covered CPT/HCPCS codes, visit limits (commercial), daily limits, and exclusions.

Commercial visit limit12 visits/yr

Daily treatment limit1 per day

INTEGRITY visit limitNo annual limit

Medical necessity & coverage rules

General Medical Necessity

All services must be medically necessary to qualify for reimbursement. Neighborhood may use the following criteria to determine medical necessity:

General Medical Necessity - top level

Medical necessity sources: National Coverage Determination (NCD) criteria applied where relevant
Medical necessity sources: Local Coverage Determination (LCD) criteria applied where relevant
Medical necessity sources: Industry accepted criteria such as Interqual
Medical necessity sources: Rhode Island EOHHS recommendations
Medical necessity sources: Neighborhood's Clinical Medical Policies (CMP)

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title

INTEGRITY product coverage rules

INTEGRITY product coverage rules - top level

No annual limit on chiropractic visits
Daily treatment limit: Treatment limited to not more than one treatment per day
Medical review: Treatment is based on medical review
X-rays not paid: No coverage/payment for x-rays or other diagnostic/therapeutic services ordered, taken, or interpreted by a chiropractor (x-rays may be used for documentation only)

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Commercial product coverage rules

Commercial product coverage rules - top level

Visit limit: Chiropractic benefit limited to twelve (12) visits per plan year12 visits per plan year
Initial evaluation prior to beginning chiropractic treatment is covered when billed with the appropriate E&M code
Daily treatment limit: Treatment limited to not more than one treatment per day
X-rays not paid: No coverage/payment for x-rays or other diagnostic/therapeutic services ordered, taken, or interpreted by a chiropractor (x-rays may be used for documentation only)

Daily visit limits (Medicare-aligned rule)

Daily visit limits - top level

One treatment per day: Limited to not more than one treatment per day1 per day
Room/ward fees not covered: Room or ward fees for multiple daily visits (intensive care concept) are not covered; Medicare reimbursement limited to one treatment per day

Exclusions

Exclusions - INTEGRITY

Exclusions - INTEGRITY - top level

Maintenance Therapy
Services 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 excluded.
Room/Ward fees for Intensive Care: Room/Ward fees for 'Intensive Care' treatment
Intensive Care concept: multiple daily visits (as many as four or five in a single day) with room/ward fees charged; room/ward fees are not covered and reimbursement limited to one treatment per day.
Non-musculoskeletal conditions: Treatment for non-musculoskeletal conditions

Exclusions - Commercial

Exclusions - Commercial - top level

Maintenance Therapy
Maintenance Therapy: services that seek to prevent disease, promote health and prolong and enhance the 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 excluded.
Non-neuromusculoskeletal conditions
Asymptomatic persons or persons without an identifiable clinical condition
No improvement after two weeks: Additional treatment with no documented improvement after initial two weeks
No improvement after 30 days modified treatment: Additional treatment after 30 days of modified treatment

Covered codes

Covered - Chiropractor CMT codesCPTCovered

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

Covered - Chiropractor with Physiotherapy license (modalities & therapeutic procedures)CPT|HCPCS|HCPCSCovered

97010	Application of a modality; 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

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Billing, documentation & authorization requirements

Billing Rule

One treatment per day limit

Providers must bill no more than one chiropractic treatment per member per day; room/ward fees for multiple daily visits are not reimbursed.

Medicare-aligned daily visit limit: one treatment per day; room/ward fees for multiple daily visits are not covered.

Billing Rule

Commercial visit limit

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

12 visits/plan year

Documentation Required

Medical necessity documentation

Providers must maintain medical records that support billed services and medical necessity; Neighborhood may request records and follows CMS documentation standards.

Prior Authorization

Prior authorization references

Providers must verify eligibility, coverage and authorization criteria prior to services and refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for PA requirements.

See Neighborhood's plan specific Prior Authorization Reference page and Clinical Medical Policies for PA requirements.

Billing Rule

Code set and timely filing

Submit complete claims within contractually determined timely filing guidelines; coding must follow CPT, ICD-10-CM, and HCPCS standards.

Denial Risk

Non-covered x-rays and diagnostics by chiropractor

Claims for x-rays or other diagnostic/therapeutic services ordered, taken, or interpreted by a chiropractor will not be paid (x-rays may be used solely for documentation).

Denial risk: imaging or diagnostic/therapeutic services billed by a chiropractor are not covered and may be denied.

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 excluded.

Intensive Care concept of treatmentMultiple daily visits (as many as four or five in a single day) with room/ward fees charged; room/ward fees are not covered and reimbursement limited to one treatment per day.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChiropractic Services Payment Policy 12.01.21

Policy CodePolicy N/A

Change TypePolicy Review / Creation (2021)

Effective Date

Next Review Date

Key ActionProviders must bill no more than one chiropractic treatment per member per day; room/ward fees for multiple daily visits are not reimbursed.

SourceLink

On This Page

OpenPayer

Chiropractic Services Payment Policy 12.01.21

Policy overview

Medical necessity & coverage rules

Exclusions

Covered codes

Billing, documentation & authorization requirements

Definitions

Policy changes & review timeline