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Professional Services -

Chiropractic Services

Chiropractic physicians must use the codes listed in this section to bill for services. In addition, they must use the appropriate CPT® codes for radiology, office visits and case management services and HCPCS codes for miscellaneous materials and supplies.

CHIROPRACTIC EVALUATION AND MANAGEMENT

Chiropractic physicians may bill the first 4 levels of new and established patient office visit codes. L&I uses the CPT® definitions for new and established patients. If a provider has treated a patient for any reason within the last 3 years, the person is considered an established patient. Refer to a CPT® book for complete code descriptions, definitions and guidelines.

The following payment policies apply when chiropractic physicians use E/M office visit codes:

• A new patient E/M office visit code is payable only once for the initial visit.
• An established patient E/M office visit code is not payable on the same day as a new patient E/M office visit code.
• Office visits in excess of 20 visits or that occur more than 60 days after the first date you treat the worker require prior authorization.
• Modifier –22 is not payable with E/M codes for chiropractic services.
• Established patient E/M codes are not payable in addition to L&I chiropractic care visit codes for follow-up visits.
• Refer to the Chiropractic Care Visits section for policies about the use of E/M office visit codes with chiropractic care visit codes.

Case Management

Refer to Case Management Services, page 38 in the Evaluation and Management section for information on billing for case management services telephone calls, team conferences, and secure email). These codes may be paid in addition to other services performed on the same day.

Consultations

Approved chiropractic consultants may bill the first 4 levels of CPT® office consultation codes. L&I periodically publishes:

• A policy on consultation referrals and
• A list of approved chiropractic consultants

The most recent policy, list of approved consultants and how to become a chiropractic consultant is available on the L&I web at http://www.lni.wa.gov/ClaimsIns/Providers/Becoming/Chiropractic/default.asp

Physical Medicine Treatment

Local code 1044M (physical medicine modality (ies) and/or procedure(s) by attending doctor not board qualified/certified in Physical Medicine & Rehabilitation (PM&R)) may be billed up to 6 units per claim (not per attending doctor), except when the doctor practices in a remote area. Refer to the previous section Non-Board Certified/Qualified Physical Medicine providers, page 63 for more information. Documentation of the visit must support billing for this procedure code.

CPT® physical medicine codes 97001-97799 are not payable to chiropractic physicians.

Powered Traction Devices

Powered traction devices are covered as a physical medicine modality under existing physical medicine payment policy. The insurer will not pay any additional cost when powered devices are used. Published literature has not substantially shown that powered devices are more effective than other forms of traction, other conservative treatments or surgery. This policy applies to all FDA-approved powered traction devices. When powered traction is a proper and necessary treatment, the insurer may pay for powered traction therapy administered by a qualified provider. Nonboard certified/qualified physical medicine providers must use 1044M. Therapy is limited to 6 units per claim except when the doctor practices in a remote area. Only 1 unit of the appropriate billing code will be paid per visit, regardless of the length of time the treatment is applied. For additional information see "Powered Traction Therapy", page 65 in the Physical Medicine section of this document.

Complementary and Preparatory Services

Chiropractic physicians are not separately paid for patient education or complementary and preparatory services. L&I defines complementary and preparatory services as interventions used to prepare a body region for or facilitate a response to a chiropractic manipulation/ adjustment. The application of heat or cold is considered a complementary and preparatory
service. Examples of patient education or counseling include discussion about:

• Lifestyle
• Diet
• Self-care and activities of daily living
• Home exercises

CHIROPRACTIC CARE VISITS

Chiropractic care visits are defined as office or other outpatient visits involving subjective and objective assessment of patient status, management and treatment. CPT® codes for chiropractic manipulative treatment (98940-98943) are not covered. L&I collaborated with the Washington State Chiropractic Association and the University of Washington to develop the local codes that are covered for chiropractic services. The codes account for these components of treating workers:

• Professional management (clinical complexity), and
• Technical service (manipulation and adjustment)

Local codes for chiropractic care visits:

2050A Level 1: Chiropractic Care Visit (straightforward) ......................................... $ 41.20
2051A Level 2: Chiropractic Care Visit (low complexity) ......................................... $ 52.76
2052A Level 3: Chiropractic Care Visit (moderate complexity) ................................ $ 64.29

Clinical complexity is similar to established patient evaluation and management services, but emphasizes factors typically addressed with treating workers. Factors that contribute to visit complexity include:

• The current occupational condition(s)
• Employment and workplace factors
• Nonoccupational conditions that may complicate care of the occupational condition
• Chiropractic intervention(s) provided (including the number of body regions manipulated)
• Care planning and patient management
• Response to care

NOTE: The number of body regions being adjusted is only one of the factors that may contribute to visit complexity. It is not the only factor as it is in the CPT® chiropractic manipulation treatment (CMT) codes.

Payment Policies for Chiropractic Care Visits

Only 1 chiropractic care visit code is payable per day.

Extremities are considered as one body region and are not billed separately.

Office visits in excess of 20 visits or that are more than 60 days after the first date you treat the worker require prior authorization per WAC 296-20-03001(1).

Modifier –22 will be individually reviewed when billed with chiropractic care visit local codes (2050A-2052A). Submit a report detailing the nature of the unusual service and the reason it was required. Payment will vary based on the review findings. This modifier is not payable when used for noncovered or bundled services (for example: application of
hot or cold packs).

Use of Chiropractic Care Visit Codes with E/M Office Visit Codes

Chiropractic care visit codes (local codes 2050A-2052A) are payable in addition to E/M office visit CPT® codes (99201-99204, 99211-99214) only when all of the following conditions are met:

The E/M service is for the initial visit on a new claim; and

The E/M service is a significant, separately identifiable service (exceeds the usual preand post-service work included in the chiropractic care visit); and

Modifier –-25 is added to the patient E/M code; and

Supporting documentation describing the service(s) is in the patient‘s record.

BILLING TIP: When a patient requires reevaluation for an existing claim:

• Either an established patient E/M code or
• A chiropractic care local code (2050A-2052A) is payable and
• Modifier –25 is not applicable in this situation.

Selecting the Level of Chiropractic Care Visit Code

The following table outlines the treatment requirements, presenting problems and face-to-face patient time involved in the 3 levels of chiropractic care visits. Clinical decision making complexity is the primary component in selecting the level of the visit. L&I defines clinical decision making complexity according to the definitions for medical decision making complexity
in the Evaluation and Management Services Guidelines section of the CPT® book.

If the clinical decisionmaking is…	and the typical number of body regions* manipulated is…	and the typical faceto- face time with patient or family is…	Then the appropriate billing code is:
Straightforward	Up to 2	Up to 10-15 minutes	Level 1 (2050A)
Low complexity	Up to 3 or 4	Up to 15-20 minutes	Level 2 (2051A)
Moderate complexity	Up to 5 or more	Up to 25-30 minutes	Level 3 (2052A)

* Body regions for chiropractic services are defined as:

• Cervical (includes atlanto-occipital joint)
• Thoracic (includes costovertebral and costotransverse joints)
• Lumbar
• Sacral
• Pelvic (includes sacro-iliac joint)
• Extraspinal: Any and all extraspinal manipulations are considered to be one region.

Extraspinal manipulations include:

• Head (including temporomandibular joint, excluding atlanto-occipital)
• Lower extremities
• Upper extremities
• Rib cage (excluding costotransverse and costovertebral joints)

Chiropractic Care Visit Examples

The following examples of chiropractic care visits are for illustrative purposes only. They are not intended to be clinically prescriptive.

CHIROPRACTIC INDEPENDENT MEDICAL EXAMS

Chiropractic physicians must be approved examiners by the department prior to performing independent medical exams (IMEs) or impairment ratings. Before applying for approval, chiropractic physicians must meet the following requirements:

• Complete two years as an approved chiropractic consultant and
• Complete an impairment rating course approved by the department;

The above mentioned course is offered as part of the Chiropractic Consultant Program. For more information refer to http://www.Lni.wa.gov/ClaimsIns/Providers/Treatment/Chiro/chiroConsult.asp or the Medical Examiners’ Handbook (publication F252-001-000). http://www.Lni.wa.gov/FormPub/Detail.asp?DocID=1668.

At the request of the department or self-insurer, attending chiropractic physicians who are approved examiners may:

• Perform impairment ratings on their own patients or
• Refer to an approved examiner for a consultant impairment rating. See page 90, later in this section.

CHIROPRACTIC RADIOLOGY SERVICES

Chiropractic physicians must bill diagnostic X-ray services using CPT® radiology codes and the policies described in the Radiology Services section, page 59.

When medically necessary, X-rays immediately prior to and following the initial chiropractic adjustment are allowed without prior authorization. X-rays subsequent to the initial study require prior authorization.

Only chiropractic physicians that are on L&I‘s list of approved radiological consultants may bill for X-ray consultation services. To qualify, a chiropractic physician must be a Diplomat of the American Chiropractic Board of Radiology and must be approved by L&I.

SUPPLIES

See the Supplies, Materials and Bundled Services section, page 123 to find information about billing for supplies.