State of Delaware Mandate
Delaware law, 24 Delaware Code Chapter 7 requires coverage for chiropractic services subject to the operation of applicable policy provisions such as utilization management and member cost sharing.  Chiropractic practice includes the diagnosis of misaligned or displaced vertebrae and treatment through manipulation or adjustment of the spine other skeletal structures and other adjunctive procedures. 

Manipulation:

• Chiropractic clinical practice generally encompasses manipulation or adjustment and may include physical medicine modalities or use of durable medical equipment (i.e. sacral supports).
• The following is eligible for reimbursement:
  • Manual Therapy Techniques
  • Chiropractic Manipulative treatment; spinal, 1 - 2 regions.
  • Chiropractic Manipulative treatment; spinal, 3 - 4 regions.
  • Chiropractic Manipulative treatment; spinal, 5 regions.
  • Chiropractic Manipulative treatment; extraspinal, one or more regions.
• Chiropractic coverage is limited to one (1) visit per day.

Physical Medicine Procedures

• Physical medicine procedures are covered in conjunction with a manipulation or can be billed alone.
• Physical medicine modality (hot or cold packs) is often considered an inherent part of manipulation. This service when routinely performed is not eligible for separate payment when reported on the same day as a manipulation service.  When a modality (hot or cold packs) is performed on a separate body region, 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.

Daily Maximum

• There is a daily dollar maximum for chiropractic care.  Included in the daily maximum are:
  • Spinal manipulation; and
  • Physical therapy codes (approved for chiropractors).

Other approved services for chiropractors such as radiology and office visits for evaluation and re-evaluation are not included in the daily maximum.

X-Rays

• Chiropractors can bill and perform x-rays in their offices and will be paid at the chiropractic x-ray benefit level.
• Serial x-rays (i.e., cervical x-ray or thoracic x-ray) are considered appropriate. Full spine x-rays are considered inappropriate.
• Repeat x-rays are not considered a customary treatment practice. However, repeat x-rays may be considered eligible for coverage when ANY of the following conditions are met:
  • Documentation of clinical regression; or
  • Significant re-injury/exacerbation; or
  • Suspicion of advancing underlying pathology.

Note: Repeat of four or more x-rays within 31 days will suspend to Claims Review.

Covered x-rays are noted below. 

Office Visits

• Benefits are provided for one (1) initial evaluation (codes 99201-99205).
• Benefits are provided for the re-evaluation (codes 99211-99215) at 30-day intervals.
• When both an evaluation/re-evaluation and a chiropractic manipulation are performed on the same day both the E/M and manipulation are covered if the E/M is billed with a modifier 25.  (If the E/M is billed without the modifier 25, only the manipulation is covered.
• Office consultation codes 99241, 99242, 99243, 99244 are covered.

DME

·         Items considered to be non-covered DME would also be non-covered in this situation.

·         The Chiropractor can provide some DME equipment (e.g., cervical collars and lumbosacral supports), which must be billed and reimbursed if eligible as DME. The following are covered for chiropractors:

o    Cervical, flexible non-adjustable (foam collar)

o    Cervical, semi-rigid, adjustable (plastic collar)

·         Reimbursement of the DME item as a piece of Durable Medical Equipment is subject to the customer contract.

Laboratory Procedures are not covered when performed in the Chiropractors office. If a prescription is given to the member, a lab may do the study but the study must be consistent with the diagnosis. For those managed care accounts with a preferred lab benefit, a preferred lab must be used to obtain maximum benefit.

For non-par Chiropractors, pay the customer according to the same rules for par-Chiropractors.

Nutritional Supplements are not covered items. To be considered for reimbursement the item must be a prescription drug. Chiropractors are excluded from prescribing drugs/pharmaceuticals.

Orthopedic Supports that are considered eligible for reimbursement must be consistent with the diagnosis for which treatment has been sought. The durable medical equipment guidelines regarding coverage would also apply. Chiropractors can order/prescribe DME equipment which would be covered under the DME benefit.

Exclusions

• The following are exclusions:
• Thermography; and
• Moire contourography; and
• Acupuncture; and
• Invasive tests performed by the chiropractor