Manipulation or chiropractic (therapeutic) 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.

West Virginia Senate Bill 273 seeks to promote the physical and mental health of West Virginia citizens by, in relevant part, attempting to reduce opioid addiction by prescribing alternative treatments to help individuals manage chronic pain.  Senate Bill 273, in relevant part, amends the Chapter 16 of the West Virginia Code, relating to Public Health to add §16-54-1 et seq. (Treatment of Pain) (the “Act”).  The Act is effective June 7, 2018 and applies to insurers who offer insurance policies in West Virginia, the Bureau for Medical Services, and the Public Employees Insurance Agency.

The requirements of the Act are as follows:

(a)    When patients seek treatment for any of the myriad conditions that cause pain, a health care practitioner shall refer or prescribe to a patient any of the following treatment alternatives, based on the practitioner’s clinical judgment and the availability of the treatment, before starting a patient on an opioid: physical therapy, occupational therapy, acupuncture, massage therapy, osteopathic manipulation, chronic pain management program, and chiropractic services, as defined in §30-16-3 of this code.

(b)   Nothing in this section should be construed to require that all of the treatment alternatives set forth in (a) are required to be exhausted prior to the patient receiving a prescription for an opioid.

(c)    At a minimum, an insurance provider who offers an insurance product in this state, the Bureau for Medical Services, and the Public Employees Insurance Agency shall provide coverage for 20 visits per event of physical therapy, occupational therapy, osteopathic manipulation, a chronic pain management program, and chiropractic services, when ordered by a health care practitioner to treat conditions that cause chronic pain.

(d)   A patient may seek treatment for physical therapy, occupational therapy, osteopathic manipulation, a chronic pain management program, and chiropractic services prior to seeking treatment from a practitioner and a practitioner referral is not required as a condition of coverage by the Bureau for Medical Services, the Public Employees Insurance Agency, and any insurance provider who offers an insurance product in this state. Any deductible, coinsurance, or co-pay required for any of these services may not be greater than the deductible, coinsurance, or co-pay required for a primary care visit.

(e)   Nothing in this section precludes a practitioner from simultaneously prescribing an opioid and prescribing or recommending any of the procedures set forth in (a).

Manipulation, chiropractic manipulation, and physical medicine services 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) physical medicine modalities/procedures on any given date of service, per performing provider including:
      • Modalities; or
      • Therapeutic procedures; or
      • Muscle and range of motion (ROM) testing; or  
      • Physical tests and measurements; or
      • Orthotic management and prosthetic management.

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

Manipulation, chiropractic manipulation, and physical medicine services 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, CMT, any of the physical medicine procedures, therapeutic procedures, muscle and ROM testing, 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. 

Services exceeding the limitation will be 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 

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 includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies. 

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

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

*Spinal manipulation is not considered a habilitative service.

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.

The following services 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. This is not an all-inclusive list:

• Phonophoresis; and  
• Qi-Gong; and  
• Cranial Manipulation/Cranio-sacral therapy; and  
• Vertebral Axial Decompression (examples include, but are not limited to, VAX-D, DRX9000, Spine Med, Tru-Trac Traction Table); 

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 conditionor
• Distinctly different indications, which are separately identifiable and unrelated to the manipulation. 

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 E/M service when medical care is reported for any three (3) reasons, to identify it as a separately identifiable service, in accordance with these guidelines.