Evaluation and Management Services with Chiropractic Manipulative Treatment

Reimbursement Policy:
Evaluation and Management Services with Chiropractic Manipulative Treatment

Effective Date:
July 27, 2015

Last Revised Date:
November 22, 2021

Purpose:
Provide guidelines for the reimbursement of Evaluation and Management (E&M) Services performed in conjunction with Chiropractic Manipulative Treatment when billed by professional providers.

Scope
All products are included except for

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
• Commercial COB or as noted below.
• ITS Home Local business Par
• ITS Home National Accounts Par
• MPL Non-Par
• Flex link
• ITS Host MA non-PPO
• ITS Host MA PPO Non-Par

This policy applies to insured and Administrative Services Only (ASO) accounts.

Definitions:
Chiropractic Manipulative Treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. The treatment may be accomplished using a variety of techniques. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment.

For purposes of CMT, the five spinal regions referred to are:

• cervical (includes atlanto-occipital joint),
• thoracic (includes costovertebral and costotransverse joints),
• lumbar
• sacral
• pelvic (sacroiliac joint)

CMT of the extremities is defined as a separate region (extra spinal).

Policy

1. CMT E&M Services: According to CPT guidelines, CMT codes include a pre-manipulation patient assessment. An E&M service may be reported in addition to CMT if the member’s condition requires a significant, separately identifiable E&M service that is above and beyond the usual pre-service and post service work associated with the CMT. In such instances the provider should append modifier 25 to the E&M code and ensure that the appropriate documentation is included in the patient’s medical record in accordance with CMS guidelines.

   It is appropriate to separately and additionally report an E&M service only in the following conditions:

   • Initial evaluation of a new member or condition; or a reevaluation of an established patient’s progress under a current treatment plan every thirty (30) days;

   • Acute exacerbation of symptoms or a significant change in the member's condition; or

   • A distinct and different indication which is separately identifiable and unrelated to the manipulation.

   It is not appropriate for an E&M service to be routinely reported with CMT with modifier 25 as if the E&M is always a separate and identifiable service rather than a component of the CMT.

2. When reporting an E&M service as separate to CMT for any of the three (3) reasons cited above, the provider should append modifier 25 to the E&M code. If modifier 25 is not appended, the E&M service will not be reimbursed as it is considered included within the CMT code.

3. An E&M service for a new patient visit (see 7. a. below) is reimbursable once every three (3) years.

4. An E&M service for an established patient is reimbursable without the need for submission of medical record support one time per every thirty (30) day period within an episode of care.¹ An episode of care in this context is defined as a treatment plan under which services are performed to address the same diagnosis by the same provider for a given presenting condition or injury.

5. Other than in the circumstances described in section 4 above, an E&M service is reimbursable more than once per episode of care only when one or more of the indications in section 1 above exist and medical records are submitted in support of the claim.

6. Level 2-5 E&M codes (99202 – 99205) are used to bill an office visit for the evaluation and management of new patients; and Level 2-5 E&M codes (99212 – 99215) are used to bill these services for established patients

7. Definitions/clarifications for the above Policy statements

   • A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

   • An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

   • The level of E&M service reported should be consistent with the complexity of the history, physical examination and medical decision making involved in the member encounter as outlined in the AMA CPT Manual and CMS guidelines and the diagnoses submitted on the billing or claim form must support the complexity of the service rendered.

   • Based on CMS guidelines for E&M coding, it is unlikely that all or even a majority of a practice’s patients require the medical decision-making skills that support the billing of a level 4 or 5 E&M code.

   • Medical Records Documentation for E&M services claims:

     • Medical record documentation will be requested and reviewed to support all claims that are submitted with level 4 or 5 E&M codes. No such claims will be approved without the required medical record support being submitted.

     • Medical record documentation will also be requested and reviewed to support claims submitted for established patients when billing more than one E&M service within a thirty (30) day period within an episode of care (see definition in section 4 above). No such claims will be approved without the required medical record support being submitted.

   • Documentation in the member's medical record should include the key components as well as the reasons for performing the separate E&M service. Documentation must meet CMS requirements on this matter.

Claim Submission guidelines
All regions treated must include a corresponding diagnosis code on the billing or claim form.

By definition, CPT code 98943 applies to CMT of 1 or more extraspinal regions; therefore only one unit of service is eligible for reimbursement per date of service.

Documentation in the member’s medical record must include sufficient information to substantiate the need for administering CMT to any given region.

Medical record documentation must be supplied to support the submission of the following:

• All level 4 or 5 E&M codes.
• Billing more than one E&M service within a thirty (30) day period within an episode of care for an established patient.

CMT with mechanical or computer operated devices
In instances where chiropractic manipulation is provided with the assistance of various mechanical or computer operated devices, no additional allowance will be considered for use of the device or for the device itself.

Procedure
Claims submitted with an E&M code of level 4 or 5 that are not accompanied by supporting medical record documentation will pend while medical record documentation is requested and reviewed to support the level of E&M coding. Upon review of the medical record documentation, if the Evaluation and Management service is not supported it will be denied.

Claims submitted with a level 1, 2 or 3 E&M code that is appended with modifier 25 will be considered for reimbursement once every thirty (30) day period within an episode of care without the need for accompanying medical record support.

Claims submitted with an E&M code more than once per thirty (30) day period within an episode of care without supporting medical records will be pended while medical record documentation is requested and reviewed to support the necessity of a second E&M during that thirty (30) day period within the episode of care.

An episode of care in this context is defined as a treatment plan under which services are performed to address the same diagnosis by the same provider for a given presenting condition or injury services.

Claims submitted for level 1, 2 or 3 E&M codes that are provided on dates of service separate from manipulation services will be allowed with no limits.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

¹ Horizon BCBSNJ reserves the right to request and review records in circumstances that suggest that recurring E&M services submissions appear to be more than would typically be necessary in a given case or cases.

CPT® is a registered trademark of the American Medical Association.

History:
6/4/2014: Policy approved
4/23/2015: Content revised to better convey episode of care and submission of medical records information
2/24/2016: Split single policy into 2 distinct policies: one for CMT and one for OMT. No changes to policy guidelines or procedures.
7/22/2019: Process changed to deny rather than pend.
2/22/2021: Deleted reference to "Level 1" and procedure codes 99201, 99211 from #6 in "Policy" section.
11/22/2021: Deleted “ITS Host MADV,” added “ITS Host MA non-PPO,” “ITS Host MA PPO Non-Par” in “Scope” section.

Policy 096_v5.0_11222021