Manipulation (98925-98929, 98940-98943)is a passive maneuver in which a joint(s) is suddenly moved beyond the normal physiological range of movement without exceeding the boundaries of anatomic integrity. This treatment may be accomplished by a variety of techniques. The most common techniques include short lever, high velocity manipulation directed at a specific vertebra or joint for the purpose of taking the joint to the paraphysiological ranges of motion in the treatment of subluxation; and long lever, low velocity manipulation intended to correct or impact numerous vertebrae or joints at one time for the purpose of relieving somatic dysfunction.

The typical manipulation encounter for a patient includes a progress report from the patient and brief physical examination which determines the method, location, and intensity of the manipulation, if it is medically indicated.

Manipulation includes a pre-manipulation assessment. This means that a separate evaluation and management (E/M) service should only be paid in the following circumstances:

1. Initial examination of a new patient or condition;
2. Acute exacerbation of symptoms or a significant change in the patient's condition; or
3. Distinctly different indications, which are separately identifiable and unrelated to the manipulation.
   

Code 97140 (manual therapy techniques) is also considered an inherent part of a manipulation procedure and is not eligible for separate payment when reported on the same day as manipulation.

When codes 97010, 97124, and 97140 are performed on a separate body region, unrelated to the manipulation procedure, these procedures may be considered for separate payment. In these cases, modifier-59 should be reported with codes 97010, 97124, or 97140.

Under standard Highmark contracts, manipulation of the spine is a non-covered service and should be denied. However, certain groups as identified in the benefits schedule may have coverage for manipulation of the spine.

When a benefit, manipulation for all body regions should be paid in accordance with the following guidelines:

1. Manipulation is a covered service when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness. Manipulation should be provided in accordance with an ongoing, written treatment plan. The treatment plan should include:
   • The specific modalities/procedures to be used in treatment
   • Diagnosis
   • Degree of severity (mild, moderate, severe)
   • Impairment characteristics
   • Physical examination findings - X-ray or other pertinent findings
   • Specific statements of long and short-term goals
   • A reasonable estimate of when the goals will be reached (estimated duration of treatment, e.g., number of weeks)
   • The frequency of treatment (e.g., number of times per week)
     

   The treatment plan should be updated as the patient's condition changes.

2. Payment may be made for up to 15 medically necessary outpatient manipulation encounters per calendar year (January-December). Claims requesting outpatient manipulation encounters in excess of 15 sessions will be denied as not medically necessary, unless there is an approved treatment plan. A participating, preferred, or network provider cannot bill the member for the denied encounter. Approval by the Dedicated Unit of all manipulation encounters in excess of 15 is required before payment can be made. (NOTE: The limitation addressed in this paragraph does not apply to inpatient manipulation encounters.)

3. In addition to a treatment plan, additional documentation from the provider requesting additional sessions could include the provider's pertinent evaluation (exam findings), progress notes, and opinions about the patient's need for continued services (treatment plan). In addition, the medical history, as it relates to the outpatient manipulation encounter, must include the date of onset and/or exacerbation of the illness or injury. Any history from a previous provider is also necessary for patients who have transferred to a new provider for additional treatment.

4. Manipulation performed repetitively to maintain a level of function is not eligible for reimbursement. A participating, preferred or network provider can bill the member for the denied services. A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.
   

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Services by a chiropractor are not eligible under the Federal Employee Standard and High Option Programs.

Managed Care

The treatment plan requirements and the 15 session out-patient physical therapy cap do not apply to Managed Care Programs.

PRN References

12/1993, Spinal manipulation and medical care
06/1994, Manipulation
04/1996, Manipulation therapy
06/1996, Manipulation and physical therapy
10/1996, Manipulation and physical therapy changes
10/1996, Therapy treatment plan
12/1996, Manipulation and physical therapy treatment plan: tips for completing form 3861
02/1997, Manipulation and physical therapy update
02/1998, Manipulation therapy codes change
08/1999, Manipulation therapy reporting guidelines reminder
06/2002, Manipulation and physical therapy reporting changes explained
08/2002, Highmark deletes routine maintenance therapy code, W9700