HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
Y-9-039
Topic:
Manipulation Services
Section:
Therapy
Effective Date:
July 18, 2022
Issued Date:
July 18, 2022
Last Revision Date:
May 2022
Annual Review:
May 2022
 
 

Manipulation and chiropractic manipulation, commonly referred to as spinal and extraspinal adjustment, manual adjustment, vertebral adjustment, or spinal manipulative therapy (SMT), is the treatment of the articulations of the spine and musculoskeletal structures, including the extremities, for the purpose of relieving discomfort resulting from impingement of associated nerves or other structures (e.g., joints, tissues, muscles).

Performance of these services requires the specialized knowledge, clinical judgement and skills of a qualified physical medicine provider.

Spinal manipulation by manual or mechanical means may be used to correct a structural imbalance or subluxation related to distortion or misalignment of the vertebral column.

Extraspinal manipulation, also known as extraspinal manipulative therapy (EMT), is used to treat joint dysfunction outside of the vertebral column.

Policy Position

Manipulation and chiropractic manipulation may be considered medically necessary when ALL of the following are met:

  • Therapy is provided for a neuromusculoskeletal condition; and
  • Therapy is provided for the initial treatment of an acute condition, reinjury, or aggravation of a chronic condition; and
  • Therapy is provided for the purpose of minimizing or eliminating impairments, functional limitations, or restrictions of the condition; and
  • Therapy is provided in accordance with an ongoing, written treatment plan, appropriate for the reported condition, and is expected to result in restoration of the individual's level of function which has been lost or reduced by the condition.
    • A treatment plan includes:
      • Osteopathic Manipulative Treatment (OMT); or
      • Chiropractic Manipulative Treatment (CMT); and
      • A maximum of four (4) modalities/procedures on any given date of service, per performing provider including:
        • Muscle and range of motion (ROM) testing; or  
        • Physical tests and measurements; or
        • Therapetic exercises to develop strength, endurance, ROM and flexibility; or
        • Mechanical Traction; or
        • Neuromuscular reeducation; or
        • Therapeutic massage.

Manipulation and chiropractic manipulation provided exclusively for the convenience of the individual or provider, for relaxation, or for personal lifestyle enhancement are considered not medically necessary.

Manipulation and chiropractic manipulation, provided for ALL of the following are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

  • Non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, etc.); and
  • Prevention/maintenance/custodial care; and
  • Internal organ disorders (e.g., gallbladder, spleen, intestinal, kidney, or lung disorders); and
  • Scoliosis correction; and
  • Manipulation of infants, less than or equal to 12 months.

Physical medicine modalities and procedures are considered an inherent part of manipulation and are not eligible for separate reimbursement when performed on the same body region and reported on the same day as the manipulation (examples include, but are not limited to: techniques such as soft tissue joint mobilization, massage, myofascial release, manual lymphatic drainage, and manual traction.)

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

Manipulations can be provided manually or with the assistance of various mechanical or computer operated devices. Separate reimbursement is not eligible for use of the device, or for the device itself.

Reimbursement for visits involving OMT, or CMT, any of the physical medicine procedures, therapeutic procedures, muscle and ROM testing, and physical tests and measurement, orthotic management, and prosthetic management is limited as follows: A maximum of four (4) codes/units in any combination per date of service, per performing provider.

  • Reimbursement will be based on the highest submitted and allowed manipulation and physical medicine codes. 

Quantity of services that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

Examples of billing for medically necessary 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

95851

95852

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97139

97140

97150

97530

97535

97542

97750

97760

97761

97763

98925

98926

98927

98928

98929

98940

98941

98942

98943

G0283

S8950




Reimbursement involving any physical medicine procedures performed on a separate body region on the same day as manipulation are limited as follows:

  • Up to four (4) codes/units in any combination per date of service per performing provider.
  • Payment will be based on the highest submitted and allowed physical medicine procedures.
    • Modalities- 97012-97039, G0283, S8950
    • Therapeutic procedures- 97110-97542
    • Tests and measurements 97750
    • Muscle range of motion (ROM) testing- 95831-95852
    • Orthotic management and prosthetic management- 97760- 97763

Habilitative Therapy

Habilitative services may be considered medically necessary when the following criteria are met:

  • Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and
  • Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

NOTE:

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 reimbursement unless the member has a habilitative benefit.  

Spinal manipulation is not considered a habilitative service.

Habilitative therapy services not meeting the criteria as indicated in this policy are considered not medically necessary.

95851

95852

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97139

97140

97150

97530

97535

97542

97750

97760

97761

97763

98925

98926

98927

98928

98929

98940

98941

98942

98943

G0283

S8950




Maintenance Services

Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur. 

A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness. 

Manipulative therapy provided for maintenance rather than restoration is not eligible for reimbursement.

Physical medicine services performed repetitively to maintain a level of function are not eligible for reimbursement unless the member has habilitative services benefits.

S8890

 

 

 

 

 

 




Vertebral axial decompression (examples include, but are not limited to, VAX-D, DRX9000, Spine Med, Tru-Trac Traction Table) is considered investigational experimental/investigational and, therefore, non- covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

S9090

         



Evaluation and Management (E/M) 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 separate Evaluation and Management (E/M) service should only be paid in the following circumstances:

  • Initial examination of a new patient or condition; or
  • 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; or
  • 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. 

99202

99203

99204

99205

99211

99212

99213

99214

99215

99417

 

 

 

 




Related Policies

Refer to Medical Policy S-197, Manipulation Under Anesthesia (MUA), for additional information.

Refer to Medical Policy S-240, Trigger Point Injections, for additional information.

Refer to Medical Policy V-37, Autism Spectrum Disorders, for additional information.

Refer to Medical Policy Y-1, Physical Medicine, for additional information.

Refer to Medical Policy Y-2, Occupational Therapy (OT), for additional information.

Refer to RPC Policy RP-009, Modifiers 25, 59, XE, XP, XS XU, and FT, for additional information


Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Manipulation services is typically an outpatient procedure which is 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.


The policy position applies to all commercial lines of business



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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.