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Coverage Explanation

Provider Type

  • Participating Physician Groups (PPG)

Chiropractic Services as Medical Benefits (Original Medicare Chiropractic Coverage)

Cal MediConnect members have coverage for Original Medicare-covered chiropractic benefits of manual manipulation of the spine to correct subluxation. Prior authorization may be required, except in an emergency. Maintenance care is not considered by Original Medicare to be medically reasonable and necessary, and is not covered.

Health Net and its delegated participating physician groups (PPGs) apply Medicare's coverage criteria when determining whether a referral to a chiropractor (or equivalent manipulative practitioner) is warranted.

A chiropractor may use an X-ray or other diagnostic test, performed for diagnostic purposes, to demonstrate medical necessity before commencing treatment; however, these diagnostic tests or X-rays are not covered when ordered, taken or interpreted by a chiropractor. Therefore, if the existence of subluxation is not known, an evaluation to determine subluxation should be considered prior to issuing a denial of chiropractic treatment.

Coverage for chiropractic services is limited to those services performed by a doctor of chiropractic, osteopathy or medicine licensed by the state of California.

Cal MediConnect nursing home facility residents are covered for services provided by chiropractors, acting within the scope of their practice as authorized by California law, except that such services are limited to treatment of the spine by means of manual manipulation.

Coverage Criteria

The primary diagnosis for chiropractic coverage must be subluxation. Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact. Subluxation may be demonstrated by an X-ray or physical examination.

Chiropractors must use the acute treatment (AT) modifier when billing chiropractic claims (CPT codes 98940, 98941, 98942) to identify services that are active/corrective treatment of acute or chronic subluxation, which are covered Original Medicare benefits.

Physical therapy is not equivalent therapy. Physical therapists cannot perform manual manipulation of the spine, which is the extent of Original Medicare-covered chiropractic services under the member's medical benefits.

Chiropractic Services as Medical Benefits (Medi-Cal Chiropractic Coverage)

Chiropractic Medi-Cal benefits of manual manipulation of the spine to correct sprain, strain or dislocation of the spine or neck are covered for Cal MediConnect members only when provided by a contracted Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) provider. Chiropractic services are:

  • Limited to a maximum of two services per month, in combination with audiology, acupuncture, occupational therapy, and speech therapy services.
  • 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.

Health Net and its delegated participating physician groups (PPGs) apply Medi-Cal coverage criteria when determining whether a referral to an FQHC or RHC chiropractor is warranted.

A chiropractor may use an X-ray or other diagnostic test, performed for diagnostic purposes, to demonstrate medical necessity before commencing treatment; however, these diagnostic tests or X-rays are not covered when ordered, taken or interpreted by a chiropractor. Therefore, if the existence of subluxation is not known, an evaluation to determine subluxation should be considered prior to issuing a denial of chiropractic treatment.

Coverage for chiropractic services is limited to those services performed by a doctor of chiropractic, osteopathy or medicine licensed by the state of California.

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 below. 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

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

Last Updated: 02/11/2020