CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Chiropractic services coverage — visit limits, coding, documentation, and prior authorization

Defines coverage, visit limits, coding, documentation, and prior authorization considerations for chiropractic services for Neighborhood Health Plan of Rhode Island members across Medicaid, INTEGRITY, and Commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChiropractic services coverage — visit limits, coding, documentation, and prior authorization

Policy CodePolicy N/A

Change TypeAdded Medicaid line of business

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for medically necessary chiropractic services beyond the Medicaid annual limit of 12 visits.

SourceLink

POLICY UPDATE CHANGES

Added Medicaid line of business effective 7/1/24.

12Medicaid annual visit limit

12Commercial visit limit

1Max treatments reimbursed per day

TablesApproved procedure code sets

Coverage criteria and limits

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Covered services and visit limits

Covered when ALL of the following are met per applicable line of business:

General coverage: Chiropractic treatment services and chiropractic evaluation & management services are covered; initial evaluation prior to beginning chiropractic treatment is covered when billed with the appropriate E&M code.

Line-of-business specific limits: Medicaid: the chiropractic medicine benefit is limited to twelve (12) visits per rolling year; medically necessary services beyond twelve (12) visits are subject to prior authorization. Commercial: the chiropractic medicine benefit is limited to twelve (12) visits per plan year. INTEGRITY: there is no annual visit limit, but treatment is based on medical review and is limited to not more than one treatment per day.

Exclusions / Limitations

Not covered or limited in all lines unless otherwise specified:

Non-covered items (all lines): Diagnostic or therapeutic services ordered, taken, or interpreted by a chiropractor (including x-rays used to demonstrate subluxation) have no coverage or payment; x-rays may be used for documentation but are not payable when ordered or interpreted by a chiropractor. Room/ward fees associated with intensive care treatment are not covered.

INTEGRITY-specific exclusions: Maintenance therapy; room/ward fees for 'Intensive Care' treatment; treatment for non-musculoskeletal conditions.

Commercial-specific exclusions: Maintenance therapy; treatment for non-neuromusculoskeletal conditions; asymptomatic persons or persons without an identifiable clinical condition; additional treatment with no documented improvement after the initial two weeks; additional treatment after 30 days of modified treatment.

There is no coverage or payment for diagnostic or therapeutic services that are ordered, taken, or interpreted by a chiropractor. While x-rays or other diagnostic procedures ordered by a chiropractor may be retained in the medical record for documentation purposes, those services themselves are not payable when provided or interpreted by the chiropractor.

Maintenance therapy is defined as services that seek to prevent disease, promote health, prolong or enhance quality of life, or maintain/prevent deterioration of a chronic condition. Maintenance therapy is considered not medically necessary when further clinical improvement cannot reasonably be expected and care becomes supportive rather than corrective.

Procedures, codes, and visit limits

Approved 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.

Approved modalities for chiropractors with physiotherapy license (Table 2 part 1)CPTCovered

97010	Application of a modality to 1 or more areas; hot or cold packs.
97012	Application of a modality to 1 or more areas; traction, mechanical.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).
97016	Application of a modality to 1 or more areas; vasopneumatic devices.
97018	Application of a modality to 1 or more areas; paraffin bath.

Additional approved modalities and therapy codes (Table 2 continued)mixedCovered

97022	Application of a modality to 1 or more areas; whirlpool.
97024	Application of a modality to 1 or more areas; diathermy (eg, microwave).
97026	Application of a modality to 1 or more areas; infrared.
97028	Application of a modality to 1 or more areas; ultraviolet.
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes.
97034	Application of a modality to 1 or more areas; contrast baths, each 15 minutes.
97035	Application of a modality to 1 or more areas; ultrasound, each 15 minutes.
97036	Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes.
97039	Unlisted modality (specify type and time if constant attendance).

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Visit limits — by line of business

Medicaid visit limit12 visits per rolling year; medically necessary services beyond 12 visits are subject to prior authorization.

Commercial visit limit12 visits per plan year.

INTEGRITY utilization controlNo annual visit limit; treatment limited to not more than one treatment per day and subject to medical review.

Provider requirements and prior authorization

Prior Authorization

Prior Authorization Required

Medically necessary chiropractic services beyond the annual limit of twelve (12) visits for Medicaid members are subject to prior authorization. Providers must obtain prior authorization when submitting requests for additional visits beyond the 12-visit rolling year limit.

Medicaid: >12 visits require prior authorization

Prior Authorization

INTEGRITY utilization controls

Treatment is subject to medical review for INTEGRITY members. INTEGRITY limits care to not more than one treatment per day; there is no annual visit limit, but each treatment must be supported by review.

INTEGRITY: medical review determines treatment
INTEGRITY: ≤1 treatment per day

Documentation Required

Medical record and X‑ray documentation

Documentation in the medical record must support the services billed and the medical necessity of those services. Neighborhood may request medical records for any billed service and follows CMS standards for proper documentation. X‑rays ordered, taken, or interpreted by a chiropractor may be used for documentation to demonstrate spinal subluxation, but such x‑ray services and any diagnostic or therapeutic procedures ordered or furnished by a chiropractor are not separately covered or payable.

Medical records must substantiate billed CPT/HCPCS and medical necessity
Neighborhood may request records for any billed service; follows CMS documentation standards
Chiropractor‑performed x‑rays can be used as documentation but are not separately payable

Denial Risk

Non‑covered services that may trigger denials

Services ordered or furnished by a chiropractor that are diagnostic or therapeutic in nature may be non‑covered and can trigger claim denials. Examples include chiropractor‑performed x‑rays or other diagnostic procedures when billed separately; providers should not expect separate reimbursement for these services.

Chiropractor‑ordered diagnostic/therapeutic procedures may be non‑covered
Claims for such services may be denied if billed separately

Background

Chiropractic care focuses on evaluation and treatment of musculoskeletal and nervous system conditions using techniques such as spinal manipulation and adjunctive physiotherapy modalities. Initial evaluation and management prior to beginning chiropractic treatment are covered when billed appropriately, but therapeutic or diagnostic procedures performed or interpreted by the chiropractor (for example, x-rays used to demonstrate subluxation) are not separately payable and may only be used for documentation in the medical record.

Key definitions

Maintenance Therapy — definition & interpretation

DefinitionMaintenance 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.

Policy interpretationConsidered not medically necessary when further clinical improvement cannot reasonably be expected and care becomes supportive rather than corrective.

Implication for coverageOngoing 'maintenance' chiropractic treatment is excluded/limited when it lacks expectation of further improvement; such visits may be denied as not medically necessary.

Intensive Care (chiropractic) — definition

DefinitionIntensive Care (chiropractic): treatment approach involving multiple daily visits (as many as four or five in a single day) often with room/ward fees charged.

Coverage limitationRoom or ward fees associated with intensive care are not covered.

Reimbursement ruleReimbursement will be limited to not more than one treatment per day (per Medicare guidance noted in policy).