Manipulation or chiropractic manipulation 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.

Manipulation is a covered service when performed with the expectation of restoring the individual'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 be updated as the individual's condition changes and 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 can be for: 

• Osteopathic Manipulative Treatment (OMT); or
• Chiropractic Manipulative Treatment (CMT).

Any of the physical medicine procedures codes:

• Modalities; or
• Therapeutic procedures; or
• Tests and measurements; or
• Orthotic management and prosthetic management.  

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. 

Reimbursement for visits involving OMT, CMT, any of the physical medicine procedures, therapeutic procedures, muscle and range of motion testing, physical tests and measurement, orthotic management and prosthetic management 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. 

Examples of billing for covered services within a visit wherein up to four (4) 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

Evaluation and Management Services

Manipulation includes a pre-manipulation assessment. Time-based physical medicine services 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) 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 individual or condition; or
• Re-examination of a new individual within an episode of care to assess individual progress, current clinical status, and determine the need for any further medically necessary therapeutic level care; or
• Acute exacerbation of symptoms or a significant change in the individual's condition; or
• Distinctly different indications, which are separately identifiable and unrelated to the manipulation.

Physical Medicine Modalities

Certain physical medicine modalities and procedures 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.

Unattended massages that do not require the services of a professional provider are non-covered.

Joint mobilization and massage are considered an inherent part of a manipulation procedure and are not eligible for separate payment when performed on the same body region and reported on the same day as the manipulation.

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 individual'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 provided for physical or manipulative therapy for maintenance rather than restoration is not eligible for payment.

Habilitative Therapy

Habilitative Therapy services are 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/Rehabilitative therapy services must be reported with the 96 or 97 modifiers in conjunction with the appropriate therapy code.

Habilitative therapy is not eligible for payment, unless the member has a habilitative benefit.

*Spinal manipulation is not considered a habilitative service.

Phonophoresis

Phonophoresis is considered experimental/investigational and, therefore, non-covered due to a lack of clinical studies showing that phonophoresis therapy is effective.

Qi-Gong

• Qi-Gong Services are considered experimental/investigational and, therefore, non-covered due to lack of clinical evidence demonstrating efficacy.

Cranial Manipulation/Cranio-sacral therapy

• Cranial Manipulation and Cranio-sacral therapy is considered experimental/investigational and, therefore, non-covered due to lack of clinical demonstrating efficacy.

Modifiers 

• When massage or joint mobilization is performed on a separate body region, unrelated to the manipulation procedure, these procedures may be considered for separate payment. Modifier 59 may be reported to identify a distinct or independent service.
• Report modifier 25 with the Evaluation and Management service when medical care is reported for any three (3) reasons, to identify it as a separately identifiable service, in accordance with these guidelines.