Coverage Explanation

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 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:

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.