Chiropractic and Osteopathic Treatments - Medicare Advantage

Policy No: 138
Date of Origin: 10/01/2022
Section: Administrative
Last Reviewed: 12/01/2023
Last Revised: 12/01/2023
Approved: 12/14/2023
Effective: 03/01/2024
Policy Applies To: Medicare Advantage

This policy applies to providers or facilities providing and billing for chiropractic and/or osteopathic treatments.

Adjunctive Procedures: Physical measures such as mechanical stimulation, heat, cold, light, air, water, electricity, sound, massage, and mobilization.

Cavitation: The "pop" that occurs during a chiropractic adjustment. This happens when the vertebral surface is separated creating a vacuum that pulls in nitrogen gas.

Chiropractic Adjustment: A passive manual maneuver during which a joint complex is carried beyond the normal physiological range of motion that is applied articulations and that is intended to result in cavitation of the joint or reduce subluxation.

Chiropractic Spinal Regions: The five spinal regions are:

• Cervical region, C1 to C7, including the atlanto-occipital joint
• Thoracic, T1 through T12, including the costovertebral and costotransverse junctions
• Lumbar region, L1 through L5
• Sacral region, the sacrum, including the sacrococcygeal junction

• Pelvic region, the sacroiliac joint and other pelvic articulations

Chiropractic Extraspinal Regions: The four extraspinal regions are:

• Head
• Lower and upper extremities
• Rib cage

• Abdomen

Extraspinal Osteopathic Regions: The extra spinal osteopathic regions are:

• Head
• Lower and upper extremities
• Rib cage
• Abdomen and visceral region

• Pelvic

Maintenance Program: A therapy program that consists of activities that preserve the patient’s present level of function and prevents regression of that function. Maintenance therapy begins when the therapeutic goals of a treatment plan have been achieved or when no further progress is apparent or expected to occur.

Manipulation Therapy: A treatment involving the movement of the spinal or other body regions.

Osteopathic Manipulative Treatment (OMT): OMT is a form of manual treatment applied by a physician or other qualified health care professionals (MDs and DOs) to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of over twenty different manual treatment techniques.

Osteopathic Spinal Regions: The three spinal regions are:

• Cervical
• Thoracic
• Lumbar/Sacral

Extraspinal Osteopathic Regions – The five extraspinal regions are:

• Head
• Lower and upper extremities
• Rib cage
• Abdomen and visceral region
• Pelvic

Our health plan evaluates claims for proper reimbursement of chiropractic and osteopathic treatments, based on coding guidelines, diagnoses, and documentation provided.

When billing for chiropractic or osteopathic treatments,

• All Current Procedural Terminology (CPT®) codes must have a supporting ICD-10-CM diagnosis code to justify the level of care provided
• Correct coding guidelines must be followed
• Chiropractic manipulation codes are only reimbursable to chiropractors
• Osteopathic manipulation codes are only reimbursable to MDs and DOs
• Diagnoses that describe "pain" is not sufficient to support medical necessity for treatments. The precise level(s) of the subluxation(s) must be specified to substantiate a claim for manipulation of each spinal region(s).
• The primary diagnosis code must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation.

• Diagnoses that describe 'all spinal regions', 'upper and lower spinal' regions, and 'all affected' regions, do not support the service performed to the degree of specificity required.

98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions

• Valid diagnosis for one or two spinal regions, and

• Documentation to support manipulative treatment in one to two regions of the spine (region as defined by CPT).

98941 CMT; spinal, three to four regions

• Valid diagnosis for three to four spinal regions, or
• Valid diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings, and

• Documentation to support manipulative treatment in three to four regions of the spine (region as defined by CPT).

98942 CMT; spinal, five regions

• Valid diagnoses for five spinal regions, or
• Valid diagnoses for three spinal regions, plus two adjacent spinal regions with documented soft tissue and segmental findings, or
• Valid diagnoses for four spinal regions, plus one adjacent spinal region with documented soft tissue and segmental findings, and

• Documentation to support manipulative treatment in five regions of the spine (region as defined by CPT).

98943 CMT; extraspinal, one to five regions when benefits apply

• Validated diagnosis for one or more extraspinal regions for which manipulation has been shown to be both safe and effective, and

• Documentation to support manipulative treatment in one or more extraspinal regions (region as defined by CPT).

97140: Manual therapy techniques (e.g., mobilization, manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes when benefits apply.

• When reporting the CPT code 97140 in conjunction with CMT codes, there are six criteria that must be documented to validate the service:

  1. Manipulation was not performed to the same anatomic region or a contiguous anatomic region e.g., cervical, and thoracic regions are contiguous; cervical and pelvic regions are noncontiguous
  2. The clinical rationale for a separate and identifiable service must be documented e.g., contraindication to CMT is present
  3. Description of the manual therapy technique(s) Location e.g., spinal region(s), shoulder, thigh, etc.
  4. Location e.g., spinal region(s), shoulder, thigh
  5. Time i.e., number of minutes spent in performing the services associated with this procedure meets the timed-therapy services requirement
  6. CPT code 97140 is appended with the modifier -59 or the appropriate –X modifier

98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved

• Valid diagnosis for one or two body regions

• Documentation to support osteopathic manipulation in one to two body regions (region as defined by CPT).

98926 OMT; 3-4 body regions involved

• Valid diagnosis for three to four body regions

• Documentation to support osteopathic manipulation in three to four body regions (region as defined by CPT).

98927 OMT; 5-6 body regions involved

• Valid diagnosis for five to six body regions

• Documentation to support osteopathic manipulation in five to six body regions (region as defined by CPT).

98928 OMT; 7-8 body regions involved

• Valid diagnosis for seven to eight body regions

• Documentation to support osteopathic manipulation in seven to eight body regions (region as defined by CPT).

98929 OMT; 9-10 body regions involved

• Valid diagnosis for nine to ten body regions

• Documentation to support osteopathic manipulation in nine to ten body regions (region as defined by CPT).

Services that may not be eligible for reimbursement for MedAdvantage business:

98943; extraspinal, one to five regions when benefits apply

97140; Manual therapy techniques (e.g., mobilization, manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes when benefits apply

S8990 Physical or manipulative therapy performed for maintenance other than restoration

Local Coverage Determination L37254 Chiropractic Services

NCCI Policy Manual Chapter 10

Medicare Claims Processing Manual - Chapter 12 - Section 220

Medicare Claims Processing Manual - Chapter 23 - Section 20.9.1

Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines

Administrative Manual, Alternative Care (PDF)

Medicare Benefit Policy Manual – Chapter 15 – Section 240

Correct Coding Guidelines

Modifier 25; Significant, Separately Identifiable Service