CurrentWellpointPolicy TNWP-CD-063802-24

Adult chiropractic clinical guideline for Tennessee

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Medical-necessity, coverage, authorization, coding, contraindication, and documentation requirements for chiropractic services provided to adults enrolled in Wellpoint Tennessee Medicaid.

Policy Summary

PayerWellpoint

PolicyAdult chiropractic clinical guideline for Tennessee

Policy CodePolicy TNWP-CD-063802-24

Change TypeNo material change

Effective DateJanuary 1, 2022

Next Review DateN/A

Key ActionObtain authorization for adult chiropractic services provided to Wellpoint Tennessee Medicaid members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentWellpointPolicy TNWP-CD-063802-24

Adult chiropractic clinical guideline for Tennessee

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Medical-necessity, coverage, authorization, coding, contraindication, and documentation requirements for chiropractic services provided to adults enrolled in Wellpoint Tennessee Medicaid.

Policy Summary

PayerWellpoint

PolicyAdult chiropractic clinical guideline for Tennessee

Policy CodePolicy TNWP-CD-063802-24

Change TypeNo material change

Effective DateJanuary 1, 2022

Next Review DateN/A

Key ActionObtain authorization for adult chiropractic services provided to Wellpoint Tennessee Medicaid members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2022Authorization effective

5Covered spinal regions

2 of 4P.A.R.T. criteria required

12 mo / 3 moX-ray timing

Medical Necessity and Coverage Criteria

Core Medical Necessity

Covered when all core medical-necessity requirements are met.

Core medical necessity: The patient has a significant neuromusculoskeletal condition necessitating treatment; a spinal subluxation is demonstrated by x-ray or physical examination; the manipulation has a direct therapeutic relationship to the condition; and there is a reasonable expectation of recovery or improvement of function.

Acute, Acute Exacerbation, or Chronic Subluxation

Covered active treatment may include either acute or chronic subluxation care when improvement or functional benefit is expected.

Qualifying clinical presentation

Acute presentation: New injury or acute flare-up with expected improvement or arrest of progression or deterioration.
Chronic presentation: Further treatment is not expected to resolve the condition, but continued therapy is expected to produce some functional improvement.

Demonstration and Causal Relationship of Subluxation

Subluxation must be demonstrated and causally linked to the patient's symptoms.

Causal relationship and accepted demonstration

Accepted demonstration of subluxation
- Imaging pathway: An x-ray, CT, or MRI demonstrates spinal subluxation and the record supports its timing, interpretation, and chiropractor review.X-ray generally no more than 12 months before or 3 months after treatment initiation
  An older x-ray may be accepted for chronic conditions documented as existing longer than 12 months when permanence is reasonably supported.
- Physical examination pathway: At least two P.A.R.T. criteria are documented, including asymmetry/misalignment or range-of-motion abnormality.2 of 4 P.A.R.T. criteria
  The precise level of subluxation and changes in examination, status, and progression must be documented.

Covered Treatment Scope

Covered service scope is limited to eligible spinal manipulation.

Covered service scope: Treatment is manual manipulation of the spine, including permitted hand-held manual devices, to correct a specified spinal subluxation, and the treatment is legal in the state where performed.

The guideline addresses the cervical, thoracic, lumbar, pelvic, and sacral spinal regions.

Contraindication Management

Dynamic thrust requires clinical risk assessment.

Relative contraindication management: When a relative contraindication is present, the provider assesses the added risk, discusses it with the patient, and records the discussion in the chart.

Absolute contraindications preclude dynamic thrust near the affected site.

Imaging Demonstration of Subluxation

Spinal subluxation may be demonstrated by diagnostic imaging.

Acceptable imaging evidence: Subluxation of the spine is demonstrated by an x-ray, CT scan, or MRI.

An x-ray should generally be reasonably proximate to treatment initiation; an older x-ray may be accepted for documented chronic permanent subluxation.

Physical-Examination Demonstration of Subluxation

Spinal subluxation may be demonstrated through the P.A.R.T. physical-examination process.

P.A.R.T. examination demonstration

Required qualifying criterion: Asymmetry/misalignment or range-of-motion abnormality is present.At least 1 criterion

Ongoing Medical-Necessity Assessment

Treatment should be evaluated on an ongoing basis.

Ongoing treatment evaluation: Recheck signs and relevant symptoms during treatment, document examination and status changes at each visit, assess patient progress, and use the findings to determine whether treatment should continue or the plan should be modified.Each visit

A treatment trial should be assessed to determine whether it should continue or a different plan should be devised.

Maintenance therapy is not covered when the patient's clinical status has remained stable and further treatment is not expected to produce additional objective clinical improvement. Care that has become supportive rather than corrective is considered maintenance therapy; the AT modifier must not be used for maintenance therapy.

Treatment to extraspinal regions is not covered. This includes the head, upper extremities, lower extremities, rib cage other than the costovertebral or costotransverse joints, and abdomen.

Diagnostic or therapeutic services furnished or ordered by a chiropractor are not covered. This includes x-rays or other diagnostic tests that the chiropractor orders, performs, or interprets; those services may be used for claims-processing purposes, but coverage and payment are not available for them when furnished under the chiropractor's order.

Coverage is limited to manual manipulation of the spine, including permitted hand-held manual devices, to correct a demonstrated spinal subluxation. Treatment that is not manual spinal manipulation directed at correcting the documented subluxation is not covered.

Dynamic thrust is not permitted near the demonstrated subluxation and proposed manipulation site when an absolute contraindication is present. These include acute unstable arthropathies; acute or unstable fractures or dislocations; unstable os odontoideum; vertebral-column malignancy or infection; myelopathy or cauda equina syndrome; vertebrobasilar insufficiency for cervical manipulation; and a significant nearby major-artery aneurysm.

A nonspecific statement or diagnosis of pain does not establish medical necessity. The claim must identify the precise spinal subluxation level and document a direct causal relationship between that subluxation and the patient's symptoms.

A prolonged course of treatment is not medically necessary without clear medical-record documentation supporting the need for continued care, expected improvement or arrest of deterioration within a reasonable and generally predictable period, and the treatment's effectiveness. The record should support the duration and frequency of care, treatment goals, objective measures, progress or lack of progress, and the rationale for any prolonged course.

Coding and Billing Guidance

Not Covered Extraspinal Chiropractic TreatmentCPTNot Covered

98943

Chiropractic manipulative treatment, extraspinal, 1 or more regions

Chiropractic Treatment ModifierModifier

AT	Modifier used for active/corrective chiropractic manipulation to treat acute or chronic subluxation when reasonable and necessary

Office and outpatient evaluation and management codesCPT

99202	Office or other outpatient visit for the evaluation and management of a new patient, requiring a medically appropriate history and/or examination and straightforward medical decision making; 15-29 minutes when time is used for code selection.
99203	Office or other outpatient visit for the evaluation and management of a new patient, requiring a medically appropriate history and/or examination and low level of medical decision making; 30-44 minutes when time is used for code selection.
99212	Office or other outpatient visit for the evaluation and management of an established patient, requiring a medically appropriate history and/or examination and straightforward medical decision making; 10-19 minutes when time is used for code selection.
99213	Office or other outpatient visit for the evaluation and management of an established patient, requiring a medically appropriate history and/or examination and low level of medical decision making; 20-29 minutes when time is used for code selection.

RadiologyCPT

72020	Radiologic examination, spine, single view, specify level
72040	Radiologic examination, spine, cervical; two or three views
72050	Radiologic examination, spine, cervical; four or five views
72052	Radiologic examination, spine, cervical; six or more views
72070	Radiologic examination, spine; thoracic, two views
72072	Radiologic examination, spine; thoracic, three views
72074	Radiologic examination, spine; thoracic, minimum of four views
72080	Radiologic examination, spine; thoracolumbar junction, minimum two views
72081	Radiologic examination, spine; entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view
72082	Radiologic examination, spine; entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); two or three views

1–10 of 16

1/2

Manipulation codesCPT

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

Standard x-ray timing

Permitted timing before treatmentNo more than 12 months before initiation of a course of chiropractic treatment.

Permitted timing after treatment beginsNo more than 3 months following initiation of a course of chiropractic treatment.

Timing standardThe x-ray must be taken at a time reasonably proximate to initiation of treatment.

P.A.R.T. examination criteria

Minimum findingsDocument at least 2 of the 4 P.A.R.T. criteria.

Required qualifying finding

Authorization, Documentation, and Denial Risks

Prior Authorization

Authorization Required

Effective January 1, 2022, authorization is required for adult chiropractic services for Wellpoint Tennessee Medicaid members.

Documentation Required

Medical-Necessity Record and Plan of Care

Maintain a medical record that fully supports medical necessity, including relevant history, physical examination, and pertinent diagnostic-test or procedure results. The individualized plan of care must define the recommended duration and frequency, specific goals, objective effectiveness measures, and progress or lack of progress; document the need for any prolonged treatment course and expected improvement or arrest of deterioration within a reasonable period.

Document objective measures at the beginning of treatment and at appropriate subsequent intervals.
Provide and reinforce home programs and lifestyle modifications early in care and document them at each visit.

Policy Background

This guideline addresses chiropractic manipulation for adults with significant neuromusculoskeletal conditions and a demonstrated spinal subluxation. Subluxation may be established by qualifying x-ray, CT, or MRI evidence or by physical examination. Active treatment may address an acute subluxation or acute exacerbation when improvement or arrest of deterioration is expected, or a chronic subluxation when continued therapy is reasonably expected to produce functional improvement. Once care becomes supportive or maintenance-oriented without expected further objective improvement, it is not covered.

Policy Definitions

Acute subluxation

ConditionA new injury identified by x-ray or physical examination.

Expected treatment resultChiropractic manipulation is expected to improve the condition or arrest its progression.

Clinical categoryAcute subluxation is one of the qualifying conditions for active chiropractic treatment.

Chronic subluxation

Expected courseThe condition is not expected to significantly improve or resolve with further treatment.

Basis for continued therapyContinued therapy can reasonably be expected to produce some functional improvement.

Coverage boundary

Policy Summary

PayerWellpoint

PolicyAdult chiropractic clinical guideline for Tennessee

Policy CodePolicy TNWP-CD-063802-24

Change TypeNo material change

Effective DateJanuary 1, 2022

Next Review DateN/A

Key ActionObtain authorization for adult chiropractic services provided to Wellpoint Tennessee Medicaid members.

SourceLink

On This Page

At least 1 documented criterion must be asymmetry/misalignment or range-of-motion abnormality.

Four criteriaPain/tenderness, asymmetry/misalignment, range-of-motion abnormality, and tissue-tone changes.

Generally acceptable x-ray timing

Prior x-ray windowGenerally no more than 12 months prior to initiation of a course of chiropractic treatment.

Post-initiation x-ray windowGenerally no more than 3 months following initiation of a course of chiropractic treatment.

Reasonably proximateThe study should be reasonably proximate to the initiation of treatment unless more specific x-ray evidence is warranted.

Chronic subluxation exception

Duration documentedThe chronic condition must be documented as having existed longer than 12 months.

Permanence supportThe health record must provide a reasonable basis for concluding that the condition is permanent.

ExampleAn older x-ray may be accepted in certain chronic subluxation cases, such as scoliosis, when the documentation supports the exception.

P.A.R.T. criteria

Required numberTwo of the four P.A.R.T. criteria are required to demonstrate subluxation by physical examination.

Qualifying criterionOne of the two criteria must be asymmetry/misalignment or range-of-motion abnormality.

Available criteriaPain/tenderness, asymmetry/misalignment, range-of-motion abnormality, and tissue-tone changes.

If goals are not met, document at the concluding visit the clinical factors preventing achievement of the plan goals.

Documentation Required

Initial Visit Documentation

For the initial visit, document the complete history and present illness, a musculoskeletal and nervous-system examination, the diagnosis and level of spinal subluxation, the treatment plan, and the date of initial treatment.

History: presenting symptoms; relevant family and past health history; trauma mechanism; symptom quality, onset, duration, intensity, frequency, location, radiation, aggravating or relieving factors; prior interventions, treatments, medications, and secondary complaints.
Symptoms must directly relate to the cited subluxation level; a nonspecific statement of “pain” is insufficient.
The treatment plan must state duration and frequency, specific goals, and objective measures of effectiveness.

Documentation Required

Subsequent Visit Documentation

At every subsequent visit, record an interval history sufficient to support continued care, an interval examination of the diagnosed spinal area, the patient’s change in condition, treatment effectiveness, and the treatment provided that day.

Review the chief complaint, changes since the prior visit, and relevant systems.
Document how the visit fits the plan of care, such as the visit number in the planned course, and identify any treatment-plan change.
A full repeat P.A.R.T. examination is not required at every subsequent visit.

Documentation Required

Subluxation Demonstration

Demonstrate spinal subluxation by acceptable imaging or physical examination. For physical examination, use the P.A.R.T. process and document the qualifying findings supporting the diagnosed level.

An x-ray, CT, or MRI may demonstrate subluxation when the study shows the spinal subluxation.
P.A.R.T. demonstration requires two of four criteria, including at least asymmetry/misalignment or range-of-motion abnormality.

Documentation Required

Home Program and Episode Closure

Document individualized home programs and lifestyle modifications as early as possible, reinforce them at each visit, and record them in the medical record. When goals are not achieved, close the episode at the final visit by documenting the factors preventing goal achievement and the discharge or concluding plan.

Include ongoing recommendations for ameliorating musculoskeletal complaints.
Document closure, discharge, or other concluding-care planning in the final visit record.

Denial Risk

Relative Contraindication Counseling

Before performing dynamic thrust when a relative contraindication is present, discuss the significant injury risk with the patient and document that discussion in the chart.

Relative contraindications include joint hypermobility or uncertain stability, severe bone demineralization, spinal benign bone tumors, bleeding disorders or anticoagulant therapy, and radiculopathy with progressive neurologic signs.

Documentation Required

Imaging Report and Review

When imaging is used to demonstrate subluxation, retain the written facility report with the physician’s interpretation and diagnosis in the patient record.

This requirement applies to diagnostic studies performed in a hospital or outpatient facility.

Documentation Required

Imaging Evidence and Timing

Maintain imaging evidence that demonstrates spinal subluxation and document that it was obtained within the acceptable timing window for treatment initiation.

An x-ray is generally reasonably proximate when obtained no more than 12 months before or 3 months after initiation of chiropractic treatment.
An older x-ray may support chronic conditions such as scoliosis when the record shows the condition has existed longer than 12 months and is reasonably permanent.
A prior CT or MRI is acceptable when it demonstrates spinal subluxation.

Documentation Required

Facility Imaging Report and Chiropractor Review

For x-rays, CTs, or MRIs performed at a hospital or outpatient facility, retain the written physician report with interpretation and diagnosis, and document the chiropractor’s review identifying the level of subluxation.

The record must show review of the imaging and the relevant subluxation level.

Documentation Required

P.A.R.T. Examination Documentation

When using the P.A.R.T. examination to demonstrate subluxation, document pain or tenderness, asymmetry or misalignment, range-of-motion abnormality, and tissue-tone changes as applicable. Two of the four criteria are required, and one must be asymmetry/misalignment or range-of-motion abnormality.

P — Pain or tenderness, including location, quality, and intensity.
A — Segmental asymmetry or misalignment.
R — Abnormal active, passive, or accessory range of motion.
T — Abnormal tissue tone, texture, or temperature involving associated soft tissues.

Documentation Required

Serial Examination and Outcomes

Record changes in examination findings, patient status, progression, and relevant symptoms at every visit. The evaluation must remain ongoing and should guide treatment modification and continuation.

Recheck signs and symptoms during treatment.
Use standardized measures such as VAS, Oswestry, or Quebec scales when appropriate to document improvement or lack thereof.

Documentation Required

Records Required Upon Request

Upon request, submit the initial visit treatment plan, subsequent visits showing changes in history, physical examination, or treatment plan, and the concluding or discharge visit.

Initial Visit reference: CMS-1500 box 14 treatment plan.

Denial Risk

No Active Corrective Treatment or Expected Improvement

Support active corrective treatment with a significant neuromusculoskeletal condition, a demonstrated spinal subluxation, a direct therapeutic relationship, and a reasonable expectation of recovery or functional improvement. Once objective improvement is no longer expected and care is supportive or preventive, further treatment is maintenance therapy and is not covered.

Acute care should improve the condition or arrest its progression.
Chronic care must reasonably be expected to produce functional improvement; stable ongoing care without expected objective improvement is maintenance therapy.
For an acute exacerbation, document the onset date, nature of the deterioration, or other facts supporting medical necessity.

Billing Rule

Noncovered Service or Incorrect Modifier Use

Coverage is limited to legally performed manual manipulation of the spine to correct a subluxation. Other chiropractic services, including diagnostic or therapeutic services furnished or ordered by the chiropractor, are not covered; extraspinal treatment such as CPT 98943 is excluded.

Hand-held manual devices may assist manipulation, but there is no separate payment for the device.
Use modifier AT only for reasonable and necessary active/corrective treatment of acute or chronic subluxation; do not use it for maintenance therapy.
A modifier does not by itself establish medical necessity, and prolonged treatment must be clearly documented.

Denial Risk

Pain Diagnosis Without Localized Causal Subluxation

A diagnosis of pain alone does not establish medical necessity. Specify the precise spinal subluxation level and document that the symptoms are directly caused by and related to that level.

Identify the applicable spinal region: cervical, thoracic, lumbar, pelvic, or sacral.
Describe the location and character of symptoms and explain the causal relationship to the cited vertebral level.

Denial Risk

Unaddressed Contraindication Risk

Do not perform dynamic thrust at a proposed manipulation site when an absolute contraindication is present. For relative contraindications, weigh the risk, discuss it with the patient, and document the discussion.

Absolute contraindications include acute unstable arthropathies, acute or unstable fractures or dislocations, unstable os odontoideum, vertebral malignancy, vertebral-column bone or joint infection, myelopathy or cauda equina syndrome, cervical vertebrobasilar insufficiency, and a nearby major artery aneurysm.

Denial Risk

Insufficient Demonstration of Subluxation

Support each manipulation claim with acceptable evidence of spinal subluxation. Use qualifying x-ray, CT, or MRI evidence or document the P.A.R.T. physical-examination findings required to demonstrate subluxation.

P.A.R.T. requires two of four findings, with asymmetry/misalignment or range-of-motion abnormality among them.
Specify the subluxation level and maintain the supporting imaging or examination documentation.

Denial Risk

Missing Ongoing Progress Evaluation

The initial examination alone is not sufficient for ongoing care. At each visit, document examination changes, patient status, progression, symptom changes, treatment response, and the basis for continuing or modifying the plan.

Recheck relevant signs and symptoms throughout the treatment course.
Use objective or standardized measures when appropriate to show improvement or lack thereof.

Denial Risk

Inadequate Imaging Support

Ensure imaging support meets the timing and record requirements before relying on it to demonstrate subluxation. Address exceptions for older studies only when the record supports a chronic condition that has existed for more than 12 months and is reasonably permanent.

Use x-rays obtained no more than 12 months before or 3 months after treatment initiation unless an exception is supported.
Retain the facility physician report with interpretation and diagnosis and document the chiropractor’s review and identified subluxation level.
A prior CT or MRI is acceptable when it demonstrates spinal subluxation.

Once clinical status is stable without expectation of additional objective improvement, further manipulative treatment is maintenance therapy and is not covered.

Acute exacerbation

Nature of conditionA temporary but marked deterioration of a previously treated condition.

Functional impactThe acute flare-up significantly interferes with activities of daily living.

Treatment expectationTreatment should improve the condition or arrest deterioration within a reasonable period of time.

Chiropractic manipulative treatment (CMT)

Treatment typeManual treatment.

PurposeUsed to influence joint and neurophysiological function.

TechniquesMay be accomplished using a variety of techniques.

Maintenance therapy

Preventive purposeCare intended to prevent disease, promote health, or maintain or prevent deterioration of a chronic condition.

Supportive natureTreatment is supportive rather than corrective when further clinical improvement cannot reasonably be expected.

Coverage statusFurther manipulative treatment after clinical status has remained stable without expected additional objective improvement is not covered.

Dynamic thrust

DefinitionThe therapeutic force or maneuver delivered during manipulation.

LocationDelivered in the involved anatomic region.

Risk considerationA relative contraindication adds significant risk of injury but does not rule out use of dynamic thrust; the risk must be discussed and recorded.

P.A.R.T. evaluation process

P — Pain/tendernessPain or tenderness is evaluated in terms of location, quality, and intensity.

A/R — Alignment and motionAssess asymmetry or misalignment and range-of-motion abnormality.

T — Tissue toneAssess changes in the characteristics, tone, texture, or temperature of contiguous or associated soft tissues.

P.A.R.T. evaluation process

PurposeAn examination process used to document spinal dysfunction or subluxation.

PPain/tenderness.

AAsymmetry/misalignment.

RRange-of-motion abnormality.

TTissue-tone changes.

Subluxation

Imaging evidenceA spinal subluxation may be demonstrated by acceptable x-ray, CT, or MRI evidence.

Physical-examination evidenceIt may also be demonstrated through the required P.A.R.T. physical-examination findings.

P.A.R.T. thresholdPhysical examination requires 2 of 4 criteria, with at least 1 being asymmetry/misalignment or range-of-motion abnormality.