Payment Policy. Chiropractic Care. Policy Specific Section: September 10, 2012 November 10, 2012

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1 Payment Policy Chiropractic Care Type: Payment Policy Policy Specific Section: Payment Original Policy Date: Effective Date: September 10, 2012 November 10, 2012 Description Chiropractic is a branch of the healing arts that is concerned with human health and prevention of disease, and the relationship between the neuroskeletal and musculoskeletal structures and functions of the body. The primary focus of chiropractic is the relationship of the spinal column and the nervous system, as it relates to the restoration and maintenance of health. The primary focus of the profession is the vertebral column; however, all other peripheral articular structures and adjacent tissues may be treated, depending on state chiropractic scope of practice laws. Policy: Phase 1: Blue Shield has defined a list of allowable CPT and HCPCS Level II codes for the reimbursement of chiropractic care. These codes include the following types of services; Evaluation and Management, Chiropractic, Physical Therapy, Radiology and Durable Medical Equipment. Blue Shield will also apply all the applicable correct coding rules noted in the Provider Manual such as; NCCI, MUE and Multiple Procedure Reduction for Radiology. Phase 2: The following is Blue Shield of California policy for the reimbursement of Chiropractic Care: Chiropractic manipulative treatment and physical medicine codes from the allowable list (noted below) will be processed using a three-tiered reimbursement methodology based on the highest to lowest RVU value and will be reimbursed at a percentage of the current fee schedule. The three tiered reimbursement methodology will be applied to the reimbursement percentage to the following; when billing multiple services, individual

2 Procedures services or multiple units of the same service. Below are the reimbursement rate percentages for the three different tiers: First code with highest Relative Value Units (RVUs) Second code with the next highest RVUs, Third code with the next highest RVUs There will be no reimbursement for the fourth or subsequent codes. Percentage of Reimbursement 100% of allowed amount 60% of allowed amount 40% of allowed amount Rationale Guideline: To reference national or regional industry standards on professional claims coding and payment, whenever available and applicable. To adhere to CMS and specifically National Correct Coding Initiative (NCCI) guidelines, whenever available and applicable, to the extent that they are consistent with our guiding principles. In claims-payment scenarios where the NCCI guideline is lacking or insufficient, the PPC may develop customized payment policies that are based on other accepted or analogous industry payment standards and which reflect the PPC s principle of reasonable reimbursement only for value-added services. When both CMS and AMA are silent, Blue Shield may identify appropriate specialty input, which may include national or regional society guidelines, and expertise from specialty consultants/advisors. Documentation Required for Clinical Review No records required. Allowable Codes This Policy relates only to the services or supplies described herein. Benefits may vary according to benefit design; therefore, contract language should be reviewed before applying the terms of the Policy. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement. CPT Radiologic examination, chest; single view, frontal Radiologic examination, chest, 2, frontal and lateral; 2 of 8

3 71100 Radiologic examination, ribs, unilateral; Radiologic examination, spine, entire, survey study, anteroposterior and lateral Radiologic examination, spine, single view, specify level Radiologic examination, spine, cervical; 2 or Radiologic examination, spine, cervical; minimum of Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies Radiologic examination, spine, thoracolumbar, standing (scoliosis) Radiologic examination, spine; thoracic, Radiologic examination, spine; thoracic, Radiologic examination, spine; thoracolumbar, Radiologic examination, spine; scoliosis study, including supine and erect studies Radiologic examination, spine, lumbosacral; 2 or Radiologic examination, spine, lumbosacral; minimum of Radiologic examination, pelvis; 1 or Radiologic examination, sacrum and coccyx, minimum of Radiologic examination; clavicle, complete Radiologic examination; scapula, complete Radiologic examination, shoulder; 1 view Radiologic examination, shoulder; complete, minimum of Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction Radiologic examination, elbow; Radiologic examination, elbow; complete, minimum of 3 3 of 8

4 73090 Radiologic examination; forearm, Radiologic examination, wrist; Radiologic examination, wrist; complete, minimum of Radiologic examination, hand; Radiologic examination, hand; minimum of Radiologic examination, finger(s), minimum of Radiologic examination, hip, unilateral; 1 view Radiologic examination, hip, unilateral; complete, minimum of Radiologic examination, hips, bilateral, minimum of 2 of each hip, including anteroposterior view of pelvis Radiologic examination, femur, Radiologic examination, knee; 1 or Radiologic examination, knee; Radiologic examination, knee; complete, 4 or more Radiologic examination; tibia and fibula, Radiologic examination, ankle; Radiologic examination, ankle; complete, minimum of Radiologic examination, foot; Radiologic examination, foot; complete, minimum of Radiologic examination; calcaneus, minimum of Radiologic examination; toe(s), minimum of Application of a modality to 1 or more areas; traction, mechanical Application of a modality to 1 or more areas; electrical stimulation (unattended) Application of a modality to 1 or more areas; whirlpool 4 of 8

5 97024 Application of a modality to 1 or more areas; diathermy (eg, microwave) Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Application of a modality to 1 or more areas; iontophoresis, each 15 minutes Application of a modality to 1 or more areas; contrast baths, each 15 minutes Application of a modality to 1 or more areas; ultrasound, each 15 minutes Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Chiropractic manipulative treatment (CMT); spinal, 1-2 regions Chiropractic manipulative treatment (CMT); spinal, 3-4 regions Chiropractic manipulative treatment (CMT); spinal, 5 regions Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions 5 of 8

6 HCPC Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. A4565 A4570 E0114 E0860 G0283 L0120 Slings Splint Crutches Traction equipment, over door, cervical Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care Cervical, flexible, nonadjustable (foam collar) L0220 Thoracic, rib belt, custom fabricated 6 of 8

7 ICD9 Procedure L0621 L0625 L0628 L1830 L1902 L3670 L3710 L3908 None Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar orthotic, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment Lumbar-sacral orthotic, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Knee orthotic (KO), immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment Ankle-foot orthotic (AFO), ankle gauntlet, prefabricated, includes fitting and adjustment Shoulder orthotic (SO), acromio/clavicular (canvas and webbing type), prefabricated, includes fitting and adjustment Elbow orthotic (EO), elastic with metal joints, prefabricated, includes fitting and adjustment Wrist-hand orthotic (WHO), wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment ICD10 Procedure ICD9 Diagnosis ICD10 Diagnosis None All Diagnoses All Diagnoses 7 of 8

8 Place of Service All Places of Service Policy History This section provides a chronological history of the activities, updates and changes that have occurred with this Payment Policy. Effective Date Action Reason 9/10/2012 New Payment Policy Payment Policy Committee 11/10/2012 Policy Revised Administrative Review The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illness or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. These Policies are subject to change as new information becomes available. 8 of 8