News
Chiropractic and Podiatry Coverage
Date: 10/12/18
Coverage requirements and billing instructions
As communicated to health plans in the Department of Health Care Services (DHCS) All Plan Letter (APL) 15-003 distributed on January 26, 2015, Medi-Cal managed care plans are required to cover chiropractic and podiatry services when provided at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). Accordingly, a California Health & Wellness Plan (CHWP) Medi-Cal independent practice association (IPA) is required to cover chiropractic and podiatry services rendered at a contracting FQHC or RHC.
CHIROPRACTIC SERVICES
Chiropractic manual manipulation of the spine to correct sprain, strain or dislocation of the spine or neck is covered for Medi-Cal members only when provided by a contracting FQHC or RHC provider and is:
· Limited to a maximum of two services per calendar month.
· Limited to treatment of the spine by means of manual manipulation (only one chiropractic manipulative treatment is reimbursable when billed by the same provider, for the same recipient and date of service).
Maintenance care is not considered to be medically reasonable and necessary, and is not covered. Additionally, diagnostic tests or X-rays performed for diagnostic purposes to demonstrate medical necessity for treatment are not covered; however, diagnostic tests or X-rays ordered by a physician are covered.
Coverage for chiropractic services is limited to those services performed by a doctor of chiropractic, osteopathy or medicine licensed by the state of California. Refer to the table on page 2 for a list of ICD-10 codes for chiropractic services that may be reimbursed.
HOW TO BILL CHIROPRACTIC SERVICES
The following information is required for appropriate billing of chiropractic services.
· Must be billed with place of service (POS) 50 to indicate the service was provided at an FQHC/RHC.
· Primary diagnosis must indicate chiropractic-related care. Primary diagnosis must be indicated by an approved chiropractic diagnosis code from the ICD-10-CM table on page 2. If the relevant diagnosis code is not in the primary diagnosis code position, the claim will be denied.
· CPT code must be one of the codes shown in the CPT code table below. Evaluation and management (E&M) codes are not reimbursable.
CPT Codes and Rates for Chiropractic Services
Chiropractic services are reimbursed as follows:
CPT code |
Type of visit |
Maximum allowance |
98940 |
Chiropractic manipulative treatment (CMT); spinal, one to two regions |
$16.72 |
98941 |
Chiropractic manipulative treatment (CMT); spinal, three to four regions |
$16.72 |
98942 |
Chiropractic manipulative treatment (CMT); spinal, five regions |
$16.72 |
ICD-10-CM Diagnosis Codes Required for Chiropractic Services
Providers may be reimbursed for chiropractic services when billed in conjunction with one of the following ICD-10-CM diagnosis codes.
Chiropractic Services |
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ICD-10-CM Code |
Description |
ICD-10-CM Code |
Description |
M50.11–M50.13 |
Cervical disc disorder with radiculopathy |
S16.1 |
Strain of muscle, fascia and tendon at neck level |
M51.14–M51.17 |
Intervertebral disc disorders with radiculopathy |
S23.3 |
Sprain of ligaments of thoracic spine |
M54.17 |
Radiculopathy, lumbosacral region |
S29.012 |
Strain of muscles and tendon of back wall of thorax |
M54.31, M54.32 |
Sciatica |
S33.5 |
Sprain of ligaments of lumbar spine |
M54.41, M54.42 |
Lumbago with sciatica |
S33.6 |
Sprain of sacroiliac joint |
M99.00–M99.05 |
Segmental and somatic dysfunction |
S33.8 |
Sprain of other parts of lumbar spine and pelvis |
S13.4 |
Sprain of ligaments of cervical spine |
S39.012 |
Strain of muscle, fascia and tendon of lower back |