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.

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 and must be appropriate for the diagnosis reported. The treatment plan should include at a minimum, documentation of the following: 

• The patient’s case history;
• Findings of all examinations performed including functional limitations;
• Condition severity (mild, moderate or severe);
• Findings of diagnostic imaging studies;
• Clinical impression, including rational for changes in diagnosis;
• Treatment plan to include long and short-term goals along with a reasonable estimation of duration (i.e., number of weeks) and frequency (i.e., number of visits);
• Informed consent;
• Progress notes for each date of service to follow subjective, objective, assessment and plan format along with signature of provider who rendered the service(s);
• Specific description of anatomical site(s) or region(s) of all treatment services with identification of equipment and/or techniques utilized.

The treatment plan should be updated as the patient's condition changes. Treatment plans should be maintained in the medical records.

A typical treatment plan consists of manipulative services and/or up to four physical medicine modalities/procedures on any given date of service, per performing provider.

Reimbursement for visits involving Osteopathic Manipulative Treatment (codes 98925-98929) or Chiropractic Manipulative Treatment (codes 98940-98943) and any of the physical medicine procedure codes [modalities (97010-97039, G0283, S8950), therapeutic procedures (97110-97542), muscle and range of motion testing (95831-95852), tests and measurements (97750), orthotic management and prosthetic management (97760-97762)] are limited as follows: up to four codes/units in any combination per date of service, per performing provider. Payment will be based on the highest submitted and allowed manipulation and physical medicine codes. Services exceeding the limitation will be considered not medically necessary.

Examples of billing for covered services within a visit wherein up to four codes/units are reimbursed:

Procedure codes 98925 + 97035 + 97112 + 97112
Procedure codes 98940 + 98943-59 + 97014 + 97012
Procedure codes 98926 + 97012 + 97112 + 97112
Procedure codes 98941 + 97112 + 97112 + 97032

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. Services that do not meet the criteria of this policy will not be considered medically necessary. A Pennsylvania participating, preferred or network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records. Out of Network/Non-participating providers and providers located outside of Pennsylvania may be able to bill members if the service is denied.

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.

NOTE:

The FRAS system (Forced Recording and Analysis System) is a device that provides two functions. It analyzes intervertebral resistance and it also can be programmed to provide a low force mechanical thrust to the vertebrae. The use of this device is considered part of manipulation and should not be reported separately.

Manipulation should be reported using codes 98925-98929  for Osteopathic Manipulative Treatment (OMT) and 98940-98943 for Chiropractic Manipulative Treatment (CMT).

The pre-, intra-, and post-service components of a manipulation service include:

• An update of the patient's history regarding any changes, positive or negative, since the previous visit.
• A review of the chart, prior treatment plan, or diagnostic imaging.
• Performance of an assessment to determine the location and intensity of the patient's symptoms and medical necessity of the manipulation (with or without use of an instrument as the assessment tool, such as the FRAS System).
• Manual palpation that documents pain or tenderness including location, intensity, quality, tissue response of muscles (spasms, hypertonicity, etc.).
• Motion palpation, joint evaluation, or whatever technique is used to locate and evaluate joint dysfunction/fixations.
• The manipulation of the joint(s) identified in the evaluation to restore normal joint motion/mechanics. Proper documentation of each area manipulated also must be noted in each daily note including technique or instrumentation used if not done by hand.
• A post-manipulation evaluation of the patient's response to the treatment should be noted.
• A determination to continue, cease or minimally alter the current treatment plan.
• Patient education or instructions as clinically indicated (e.g., home exercises, activities of daily living, home use of hot or cold packs).

Evaluation and Management Services
Manipulation (OMT codes 98925-98929, CMT codes 98940-98943) includes a pre-manipulation assessment. Time-based physical medicine services (97032-97036, 97110-97124, 97140, 97530, 97535) also include the time required to perform all aspects of the service, including pre-, intra-, and post-service work. Therefore a separate Evaluation and Management (E/M) (Office or Other Outpatient New Patient Codes 99201-99205 or Established Patient Codes 99211-99215) service must be medically necessary. A separate E/M service should not be routinely reported with manipulation or time-based physical medicine services. This means that a separate Evaluation and Management (E/M) service should only be paid in the following circumstances:

• initial examination of a new patient or condition;
• re-examination of a new patient within an episode of care to assess patient progress, current clinical status, and determine the need for any further medically necessary therapeutic level care
• acute exacerbation of symptoms or a significant change in the patient's condition; or
• distinctly different indications, which are separately identifiable and unrelated to the manipulation

When reporting Evaluation and Management services, the level reported should be consistent with the complexity of the history, examination 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.

When medical care is reported for any of the three reasons cited above, report modifier "-25" with the Evaluation and Management service to identify it as a separately identifiable service, in accordance with these guidelines.

Physical Medicine Modalities
Certain physical medicine modalities{97010 hot or cold packs) and procedures (97124 massage)}, are often considered an inherent part of manipulation. These services when routinely performed are not eligible for separate payment when reported on the same day as a manipulation service.

• These guidelines apply to routine use of hot and cold packs whether they're applied before or after the manipulation service.
• Also, a routine massage of limited time duration (i.e., five minutes or less) whether performed manually or with a hand-held device is considered part of a manipulation service when performed in the same body region(s) as a manipulation.

NOTE: Unattended massages (i.e., those performed via chair, mattress or table) do not require the services of a professional provider and are not covered. Participating, preferred, and network providers can bill the member for the non-covered service. See Medical Policy Bulletin E-1, Table B for information on massage chairs, mattresses and tables.

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 performed on the same body region and 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. For example, patients may experience referred symptoms, such as sciatica to an extremity caused by spinal misalignment. In such cases, treatment of the causative diagnosis, (e.g., spinal misalignment), is medically necessary. However, separate treatment of the extremity is considered medically necessary only if objective findings demonstrate a distinct, unrelated physical problem with the extremity. Otherwise, the treatment to the extremity will be considered related to the primary service (i.e., treatment of spinal misalignment). 

When codes 97010, 97124 and 97140 are performed on a separate body regions, unrelated to the manipulation procedure, modifier "-59" should be reported with these codes.  The patient's medical record must include documentation identifying the distinct body regions and diagnoses for which these services were provided. A region includes all muscles or ligaments attached to the region being treated. For example, the trapezius muscle is in the same region as the cervical and thoracic spine.

Therapeutic procedure codes (97110 and 97140) require the provider to have direct (one-on-one) patient contact. Direct one-on-one contact requires that the provider maintain visual, verbal and/or manual contact with the patient throughout the procedure. The time frames indicated for the therapeutic procedures describe the total time (i.e., pre-service, intra-service, and post-service time) spent performing the clinical skills and/or services that attempt to improve function. Documentation in the medical record for therapeutic procedures must ascertain that the total number of minutes of treatment for services represented by timed codes is consistent with the number of units billed for those services.

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 E/M service. Assessments performed during a manipulation or as part of an Evaluation and Management encounter include the assessment of muscle strength, range of motion (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. Modifier "-59" may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier "-59" is reported, the patient’s records must support its use in accordance with CPT guidelines. Modifier "-25" may be reported with medical care (e.g., EM visits or consultations) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier "-25" is reported, the patient’s records must clearly document that separately identifiable medical care was rendered.

Phonophoresis
Procedure code 97035 should be used to report Phonophoresis. Phonophoresis is an ultrasound treatment that uses a steroidal cream in place of the usual types of conductive gels.

Phonophoresis is considered experimental/investigational. There is a lack of clinical studies showing that phonophoresis therapy is effective.

Participating, preferred, and network providers can bill the patient for the denied service.

Maintenance Services
Physical medicine services performed repetitively to maintain a level of function is not eligible for payment unless the member has Habilitative Services benefits. A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. These services generally would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness. 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 (physical or manipulative therapy performed for maintenance rather than restoration), and not eligible for payment. A participating, preferred, or network provider can bill the member for the denied service.

Habilitative Therapy
Physical medicine services ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This also includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Habilitative therapy services should be reported with the SZ modifier in conjunction with the appropriate therapy code. Habilitative therapy is not eligible for payment, unless the member has a habilitative benefit. Participating, preferred, and network providers can bill the member for denied services that exceed the member's benefit limitations.

*Spinal manipulation is not considered an habilitative service.

Refer to Medical Policy Bulletin Y-1 for information on Physical Medicine.

Documentation must include the following to validate the appropriateness of the manipulation:

• A record of the patient’s subjective complaint,
• An objective assessment or physical findings to support the manipulation,
• A clear description of the type of adjustment provided, including the body region to which the adjustment was performed, and,
• A post-manipulation evaluation of the patient’s response to the treatment.

The five spinal regions referred to in the description for CMT codes 98940-98942 are: cervical (includes atlanto-occipital joint), thoracic (includes costovertebral and costotransverse joints), lumbar, sacral, and pelvic sacro-iliac joint).

Report services based on the number of regions manipulated; for example, if two regions are manipulated, report code 98940. If more than one segment is manipulated in a single region, it is still considered one region for reporting purposes.

The five extraspinal regions identified for code 98943 are: the head (including temporomandibular joint, excluding the atlanto-occipital, lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral joints), and abdomen,

Procedure code 98943 describes treatment to one or more extraspinal regions; therefore, report the service once per session regardless of how many individual extraspinal manipulations are performed. In the event a clinically indicated extraspinal manipulation is performed on the same date of service as a spinal manipulation (code range 98940-98942), the extraspinal manipulation should be coded and billed with the addition of modifier “-59” (98943-59).

Ten regions are identified for OMT codes 98925-98929. These regions include: head; cervical; thoracic; lumbar; sacral; pelvic; lower extremities; upper extremities; rib cage; and, abdomen and visceral.

The documentation may include these phrases: spinal manipulation, spinal adjustment, manual adjustment, manual manipulation, chiropractic adjustment, chiropractic manipulation, osteopathic manipulation, or abbreviations such as CMT or OMT. It is also appropriate to record the actual chiropractic or osteopathic technique being employed.

Place of Service: Inpatient/Outpatient

Manipulation Services are typically outpatient procedures which are only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Description

Manipulation (OMT codes 98925-98929, CMT codes 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. 

*It is not always possible to move the joint beyond the normal physiological range of motion.

In addition, manipulation (OMT codes 98925-98929, CMT codes 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:

• Gonstead
• Diversified
• Toggle recoil
• Thompson drop
• Flexion-distraction
• SOT
• Logan Basic
• Activator
• FRAS
• Arthrostim
• Pro-adjuster
• Upper cervical orthogonal instrument
• Cox Flexion-Distraction

The typical manipulation service for a patient includes a progress update from the patient; a brief physical examination which determines the method, location, and intensity of the manipulation as clinically indicated, and a decision to continue or alter 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.

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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PRN
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, Blue Shield deletes routine maintenance therapy code, W9700
08/2003, Reminder: report evaluation and management codes with manipulation therapy services only under certain circumstances
02/2005, How to report maintenance manipulations
02/2005, Massage therapists services not eligible
04/2005, Manipulation services guidelines clarified
02/2006, Manipulation services guidelines explained
02/2006, Hands-free ultrasound considered investigational
04/2006, Report hands-free evaluation ultrasound with code 97799
06/2006, Manipulation services includes evaluation and management service
12/2007, Manipulation services require specific medical record documentation
12/2007, How to report time-based physical medicine services with an E/M
04/2008, Correction to number of regions identified for codes 98925-98929
10/2008, Hot or cold packs or massage performed with manipulations not covered
02/2009, Manipulation services guidelines clarified
10/2010, Therapeutic massage considered part of manipulation
06/2012, New manipulation services coverage guidelines outlined
02/2013, Phonophoresis considered investigational
10/2013, Habilitative care now covered for multiple services

CPT Assistant. 2005; 15(5): 14

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Gross A, Miller J, D’Sylvia J, et al. Manipulation or mobilization for neck pain. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004249.

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Leaver AM, Maher CG, Herbert RD, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. 2010 Sep;91(9):1313-8.

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Rubinstein SM, van Middelkoop M, Assendelft WJ, et al. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD008112.

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Senna MK, Machaly SA. Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine. 2011 August 15;36(18):1427-37.

Gurney AB, Wascher D, Schenck R, et al. Absorption of Hydrocortisone Acetate in Human Connective Tissue Using Phonophoresis. Sports Health. 2011;3(4).

AY S, Dogan SK, Evick D, Baser OC. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatology Int. 2011;31:1203–1208.

Gurney A, Wascher D, Schenck R, et al. Absorption of hydrocortisone acetate in human connective tissue using phonophoresis. Sports Health. 2011 July;3(4):346-351. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445200/?report=classic. Accessed September 30, 2013.

Vaughn DW, Kenyon LK, Sobeck CM, Smith RE. Spinal manual therapy interventions for pediatric patients: a systematic review. J Man Manip Ther. 2012 August 20;(3):153-159. http://www.ncbi.nlm.nih.gov/pubmed/23904755. Accessed September 29, 2013.

The American Osteopathic Association Policy Compendium 2013. American Osteopathic Association Osteopathic Guidelines for Manipulative Treatment (OMT) for patients with low back pain. 2013;101-123. http://www.osteopathic.org/inside-aoa/about/leadership/Pages/aoa-policy-compendium.aspx. Accessed September 30, 2013.

Oswald C, Higgins C, Assimakopoulos D. Optimizing pain relief during pregnancy using manual therapy. Can Fam Physician. 2013 August;59(8):841-842. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743693/. Accessed September 29, 2013.