Coverage Explanation
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Ancillary
With the exception of members who are under age 21, pregnant, or residents in a skilled nursing facility or long-term care, chiropractic benefits of manual manipulation of the spine to correct sprain, strain or dislocation of the spine or neck are covered for Medi-Cal members only when provided by a contracted county hospital outpatient department and hospital outpatient clinic, contracted Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) provider and other contracted chiropractic providers. Referrals may be needed for out-of-network FQHC, RHCs and IHCPs. Chiropractic services are:
- Limited to a maximum of two services per month, in combination with audiology, acupuncture, occupational therapy, and speech therapy services. Limits do not apply to members who are children under age 21, pregnant or residents in skilled nursing facility or long-term care.
- 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 or other contracted chiropractic providers 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.
- 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.
ICD-10-CM Code | Description |
|---|---|
M50.11-M50.13 | Cervical disc disorder with radiculopathy |
M51.14-M51.17 | Intervertebral disc disorders with radiculopathy |
M54.17 | Radiculopathy, lumbosacral region |
M54.31, M54.32 | Sciatica |
M54.41, M54.42 | Lumbago with sciatica |
M99.00-M99.05 | Segmental and somatic dysfunction |
S13.4 | Sprain of ligaments of cervical spine |
ICD-10-CM Code | Description |
|---|---|
S16.1 | Strain of muscle, fascia and tendon at neck level |
S23.3 | Sprain of ligaments of thoracic spine |
S29.012 | Strain of muscles and tendon of back wall of thorax |
S33.5 | Sprain of ligaments of lumbar spine |
S33.6 | Sprain of sacroiliac joint |
S33.8 | Sprain of other parts of lumbar spine and pelvis |
S39.012 | Strain of muscle, fascia and tendon of lower back |