Chiropractic services CPT code 98940, 98941, 98942



Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.
Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.
This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per month and 30 chiropractic manipulation services per beneficiary per year. Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.
Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

  • Twelve (12) chiropractic manipulation treatments for Group A diagnoses.
  • Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.
  • Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.
  • Thirty (30) chiropractic manipulation treatments for Group D diagnoses.


Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.
As published in CMS IOM, Pub. 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

CPT/HCPCS Codes

Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
98940©
Chiropractic manipulation
98941©
Chiropractic manipulation
98942©
Chiropractic manipulation

CHIROPRACTIC  Billing Tips

• No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered.

• X-rays or any other diagnostic tests ordered, taken or interpreted by the chiropractor can be used for documentation, but Medicare does not cover or pay for those services.

• This does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. 145 CHIROPRACTIC ERRORS 146 CPT Procedure Code Region Claims Reviewed (Post Pay) Claims Denied Dollars Denied Charge Denial Rate - % 98941-98942 NC 1,689 1,363$54,525.45 80.00% 98941-98942 SC 1,631 1,394 $57,393.53 85.00% 98941-98942 VA 1,653 1,386 $50,499.41 97.00% 98941-98942 WV 1,726 1,459 $50,220.46 86.00% Total 6,699 5,602 $212,638.85 

ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:



Billing and Coding Guide

This policy describes Optum’s requirements for reimbursement of CPT codes 98940, 98941, 98942 (Spinal Chiropractic Manipulative Treatment) and 98943 (Extraspinal Chiropractic Manipulative Treatment).

The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.


Extraspinal Manipulation + Spinal Manipulation

Modifier -51 (Multiple Procedures) is not required to be appended to the extraspinal CMT procedural code (98943), when billed on the same date of service as a spinal CMT code (98940-98942). 


Modifier -51 (Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940- 98943). According to “The CPT® Assistant” [December 2013], these are separate and distinct procedures and the use of modifier 51 does not apply. 


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

Documentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT).


98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions

Documentation must support that manipulative treatment occurred in three to four regions of the spine (region as defined by CPT) and one of the following:

1. validated diagnoses for three or four spinal regions

2. validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings 



CPT Code Description Documentation Requirement

98940 Chiropractic manipulative treatment (CMT) involving one to two spinal regions Medical record must document:

1. A complaint involving at least one spinal region;

2. an examination of the corresponding spinal region(s); AND

3. a diagnosis and manipulative treatment of a condition involving at least one spinal region.

Claim must record a diagnosis code (ICD-9) in the applicable region(s).



NCCI Edit

The below codes would not be paid separately if submitted with CPT code 98940 , Use appropriate Modifier.

64461 64463 64486 64487 64488 64489 95831 95832
95833 95834 95851 95852 96361 96366 96367 96368
97112 97124 97140 98926 98927 98928 98929 99201
99202 99203 99204 99205 99211 99212 99213 99214
99215 99217 99218 99219 99220 99221 99222 99223
99224 99225 99226 99231 99232 99233 99234 99235
99236 99238 99239 99281 99282 99283 99284 99285
99291  99304 99305 99306 99307 99308 99309 99310
99315 99316 99318 99324 99325 99326 99327 99328
99334 99335 99336 99337 99341 99342 99343 99344
99345 99347 99348 99349 99350 99455 99456 99460
99461 99462 99463 99465 99466 99468 99469 99471
99472  99475 99476 99477 99478 99479 99480 99485
99495  99496 99497 G0380 G0381 G0382 G0383 G0384

G0463  

Primary Diagnosis Codes
Covered for:
739.0–739.5
Non-allopathic lesions, not elsewhere classified

Secondary Diagnosis Codes
Group A Diagnoses
Covered for:
307.81
Tension headache
719.48*
Pain in joint, other specified sites

Note: When using 719.48*, you must specify spine as the site.
723.1
Cervicalgia
724.1–724.2
Other and unspecified disorders of back
724.5
Backache, unspecified
724.8
Other symptoms referable to back
728.85
Spasm of muscle
784.0
Headache
Group B Diagnoses
Covered for:
720.1
Spinal enthesopathy
721.0–721.2
Spondylosis and allied disorders (arthritis, osteoarthritis, spondyloarthritis)
721.6
Ankylosing vertebral hyperostosis
721.90–721.91
Spondylosis of unspecified site
724.79
Disorders of coccyx, coccygodynia
729.1
Myalgia and myositis, unspecified
729.4
Fasciitis, unspecified
846.0–846.3
Sprains and strains of sacroiliac region
846.8
Sprains and strains of other specified sites of sacroiliac region
847.0–847.4
Sprains and strains of other and unspecified parts of back
Group C Diagnoses
Covered for:
353.0–353.4
Nerve root and plexus disorders
353.8
Other nerve root and plexus disorders
722.91–722.93
Other and unspecified disc disorder
723.0
Spinal stenosis in cervical region
723.2–723.5
Other disorders of cervical region
Group D Diagnoses
Covered for:
721.3
Lumbosacral spondylosis without myelopathy
721.41–721.42
Lumbosacral spondylosis with myelopathy
721.7
Traumatic spondylopathy
722.0
Displacement of cervical intervertebral disc without myelopathy
722.10–722.11
Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.4
Degeneration of cervical intervertebral disc
722.51–722.52
Degeneration of thoracic or lumbar intervertebral disc
722.6
Degeneration of intervertebral disc site unspecified
722.81–722.83
Postlaminectomy syndrome
724.01–724.03
Spinal stenosis, other than cervical
724.3–724.4
Other and unspecified disorders of back
724.6
Disorders of sacrum, ankylosis
738.4
Acquired spondylolisthesis
756.11–756.12
Anomalies of spine
839.01–839.08
Other, multiple and ill-defined dislocations, cervical vertebra,
839.20–839.21
Other, multiple and ill-defined dislocations, thoracic and lumbar vertebra, closed
839.41–839.42
Other, multiple and ill-defined dislocations, other vertebra, closed
953.0–953.4
Injury to nerve roots and spinal plexus
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Please see Medicare Benefit Manual sections referenced above for national documentation requirements for Medicare payment of chiropractic services.

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