| Highmark Medical Policy Bulletin |
| Section: | Therapy |
| Number: | Y-9 |
| Topic: | Manipulation Services |
| Effective Date: | April 24, 2006 |
| Issued Date: | April 24, 2006 |
| Date Last Reviewed: |
Indications and Limitations of Coverage
When a benefit, manipulation for all body regions should be paid in accordance with the guidelines outlined in this policy. 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. Manipulations should be provided in accordance with an ongoing, written treatment plan. The treatment plan should include:
The treatment plan should be updated as the patient's condition changes. Treatment plans should be maintained in the medical records. Manipulations can be provided manually or with the assistance of various mechanical or computer operated devices. No additional payment is available for use of the device or for the device itself. A participating, preferred, or network provider cannot bill the member for these denied services.
Manipulation should be reported using codes 98925-98929 and 98940-98943. The pre-, intra-, and post-service components of a manipulation service include:
Evaluation and Management Services Manipulation (98925-98929, 98940-98943) includes a pre-manipulation assessment. This means that a separate evaluation and management (E/M) service should only be paid in the following circumstances:
When reporting evaluation and management services, the level reported should be consistent with the complexity of the history, physical and medical decision making involved in the patient encounter. Documentation in the medical record should include the components of the separate and distinct evaluation and management service as well as the reasons for performing the separate evaluation and management service. Physical Medicine Modalities Physical medicine procedures and modalities that are performed solely to relax and prepare the patient for manipulation procedure {application of hot or cold packs (97010) and massage (97124)} are considered an inherent part of manipulation. These services are not eligible for separate payment when reported on the same day as manipulation. Joint mobilization (97140) uses low velocity, low amplitude, long lever maneuvers to increase range of motion in patients with decreased passive range of motion. It can be used to treat spinal or extraspinal conditions. Code 97140 is considered an inherent part of a manipulation procedure and is not eligible for separate payment when reported on the same day as the manipulation. Participating, preferred, and network providers cannot bill the member for these denied services. 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. The patient's medical record should include documentation identifying the different body regions to which these services were provided. Procedure code 97750 [Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes] should not be used to report the physical assessment routinely performed as part of either the manipulation or the Evaluation and Management service. Assessments performed during a manipulation or as part of an Evaluation and Management encounter include the assessment of muscle strength, ROM, flexibility and endurance to establish the diagnosis and severity of the condition. For example, a patient with a shoulder strain would undergo resistive testing in various movements to determine the muscle group or motion that has been injured. It is also not appropriate to use code 97750 to report computer generated information obtained through devices such as the FRAS system. Maintenance Services Manipulation performed repetitively to maintain a level of function are 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. Maintenance therapy should be reported under procedure code S8990. Coverage for manipulation of the spine is determined according to individual or group customer benefits. Participating, preferred, and network providers can bill the member for denied services that exceed the member's benefit limitations. Refer to Medical Policy Bulletin Y-1 for information on Dry Hydro Massage. Description 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 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.
In addition, manipulation (98925-98929, 98940-98943) is a form of treatment intended to influence joint and neurophysiological function. It uses controlled force, leverage, direction, amplitude and velocity, which are directed at specific joints or anatomical regions. Manipulations can be performed manually or with use of devices (e.g., the FRAS system). Specific to chiropractic manipulation, there are many techniques used to assist in or provide the service. These techniques include, but are not limited to:
The typical manipulation service 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, and a decision to continue with the treatment plan. A more commonly used term for a manipulation is "adjustment." However, for the purposes of this policy document, the term manipulation, rather than adjustment, will be used. |
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| 98925 | 98926 | 98927 | 98928 | 98929 | 98940 |
| 98941 | 98942 | 98943 | S8990 |
Traditional (UCR/Fee Schedule) Guidelines
Standard Option will provide benefits for services rendered by chiropractors beginning January 1, 2006. Covered services include the initial office visit, the inital X-rays, and up to 10 manipulations per year. Basic Option Covered Services include the initial office visit, the initial X-rays, and up to 20 spinal manipulations per year by a preferred provider. |
Comprehensive / Wraparound / PPO / Major Medical Guidelines
Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.
Managed Care (HMO/POS) Guidelines
PRN References 12/1993, Spinal manipulation and medical care |