Description:
Chiropractic manipulative treatment (CMT) is a form of manual treatment proposed to influence joint and neurophysiological function. The primary mode of chiropractic treatment is manipulation or adjustment. This treatment may be accomplished using a variety of techniques. Manipulation is the application of a controlled force and is proposed to re-establish normal articular function. The objective of manipulation is to restore the normal mobility and range of motion within the joint. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. For the purposes of CMT, the five spinal regions referred to are:

• Cervical region (includes atlanto-occipital joint)
• Thoracic region (includes costrovertebral and costotransverse joints)
• Lumbar region
• Sacral region
• Pelvic region (sacro-iliac joint)

Policy:
Chiropractic Services may be considered MEDICALLY APPROPRIATE when ALL of the following criteria are met:

• The patient has clinical symptoms of a condition that may be improved or resolved by standard chiropractic therapy.
• A clear and appropriate treatment plan is documented, including symptoms/diagnosis being treated, diagnostic procedures and treatment modalities used, results of diagnostic procedures, treatments, reasonable anticipated length of treatments, and concurrent documentation of effect of therapy (please note the record keeping requirements in this policy).
• The chiropractic diagnostic procedures and treatments are clearly related to the patient's symptoms/condition.

Chiropractic treatment/manipulation is considered INVESTIGATIONAL when it is rendered for non-neuromusculoskeletal conditions including, but not limited to, attention-deficit hyperactivity disorder, asthma, autism spectrum disorder, dysmenorrhea, epilepsy, gastrointestinal disorders and menopause-related symptoms, as these indications remain unproven.

Chiropractic treatment/manipulation is considered INVESTIGATIONAL for the treatment of idiopathic scoliosis or for the treatment of scoliosis beyond early adolescence unless it is directly related to the treatment of pain or spasm or other medically necessary indications for chiropractic manipulation listed in this policy. This includes but is not limited to ScoliSmart treatments.

Chiropractic services are NOT covered for any of the following circumstances:

1. Maintenance programs or supportive care or preventive care (see definitions section) 
2. The following modalities:

• Acupunture
• Counseling (considered integral to the visit)
• Low-level laser therapy (cold laser therapy) is considered INVESTIGATIONAL for all indications
• Dry hydrotherapy (i.e., Aquamed, Sidmar)
• Therapeutic manipulation/modalities
• Hydrobed therapy

     3. Digital radiographic mensuration is considered INVESTIGATIONAL for all uses.

     4. Digital postural analysis is considered INVESTIGATIONAL for all uses.

The following procedures are considered INVESTIGATIONAL, as they remain unproven. This list is not all inclusive:

• Metronome therapy
• Applied spinal biomechanical engineering
• Atlas orthogonal technique
• Cranial manipulation
• Therapeutic (wobble) chair
• Vibration chairs
• Massage chairs
• Webster technique (breech babies)
• Neural organizational technique
• Active release technique
• Active therapeutic movement (ATM2)
• Advanced biostructural correction (ABC) chiropractic technique
• Bioenergetic synchronization technique
• Biogeometric integration
• Blair technique
• Bowen technique
• Chiropractic biophysics technique
• Coccygeal meningeal stress fixation technique
• ConnecTX (an instrument-assisted connective tissue therapy program)
• Cox decompression manipulation/technique
• Directional non-force technique
• FAKTR (functional and kinetic treatment with rehab) approach
• Gonzalez rehabilitation technique
• Inertial traction (inertial extensilizer decompression table)
• IntraDiscNutrosis program
• Koren specific technique
• Manipulation for infant colic
• Manipulation for internal (non-neuromusculoskeletal) disorders (applied kinesiology)
• Manipulation under anesthesia
• Moire contourographic analysis
• Network technique
• Neural organizational technique
• Neuro emotional technique
• Positional release therapy
• Sacro-occipital technique 
• Spinal adjusting devices (ProAdjuster, PulStarFRAS, Activator)
• Upledger technique and cranio-sacral therapy
• Whitcomb technique

SEE CAM 191 MEDICAL RECORDS DOCUMENTATION STANDARDS

Policy Statement:
**Many contracts do not have benefit coverage for these services. For information relating to coverage benefits, limitations and/or exclusions, please refer to the specific plan of benefits.**  

Definitions:
Adjunct Modalities: 
In addition to spinal manipulation, which is a manual therapy, other modalities, both passive and active, are often used as adjunct treatments. Passive modalities include treatments such as electrical stimulation, therapeutic ultrasound, high-voltage galvanic stimulation, therapeutic heat, cryotherapy, passive assistive exercise, traction, diathermy and massage. Passive modalities are most effective during the acute phase of treatment, as they are typically directed at reducing pain and swelling. They may also be used during the acute phase of an exacerbation of a chronic condition. The optimal duration of a course of passive modalities is a maximum of one to two months, after which their effectiveness diminishes, and patient dependency may develop. Treatment plans for patients who are at risk for developing chronic conditions should de-emphasize passive care and refocus on active care approaches. When utilizing passive modalities after a lasting physiological benefit has been reached, the modalities serve only to facilitate the manipulation and are considered integral to the manipulative procedure.

Digital Postural Analysis: 
Posture analysis is a method by which deviation in posture may be determined, theoretically identifying areas that are likely to cause or are causing pain. Various systems may be utilized to conduct posture analysis and include software systems for analyzing digital/video images. Following the procedure, a report is produced identifying posture deviations. Postural analysis may be used to document posture before and after treatment sessions, to educate individuals regarding deviations and causes of pain and to customize and monitor treatment plans. However, there is lack of evidence in the peer-reviewed published scientific literature evaluating this technology and conclusions cannot be drawn regarding the added benefit of digital postural analysis and how this technology affects treatment plans to improve clinical outcomes.

Digital Radiographic Mensuration: 
Digital radiographic mensuration, also referred to as radiographic digitization, or computer-aided radiographic mensuration analysis (CRMA), refers to a computerized analysis of osseous geometric relationships, often employed as part of postural analysis. Mensuration is a term that refers to chiropractic line measurements, with or without computer digitalization and may be used to assess subluxation and alignment. Historically, chiropractic line measurements were drawn manually on radiographs with the use of rulers, pencils and protractors. Manual marking techniques may lead to error and more recently, computer aided or digitalized mensuration has been utilized, theoretically providing results more rapidly and with less variance. Although published data comparing digital radiograph mensuration to manual methods is limited, a few results for reliability testing have been published and lend some support to concurrent validity when compared to manual methods (Troyanovich, et al., 2000). However, well-designed clinical trials supporting efficacy are lacking in the medical literature and there is insufficient evidence to support that the use of this technology adds any benefit or improvement of health outcomes when compared to standard chiropractic techniques.

Supportive Care: Supportive care is long-term treatment/care for patients who have reached maximum therapeutic benefit, but who fail to sustain benefit and progressively deteriorate when there are periodic trials of treatment withdrawal. Supportive care follows appropriate application of active and passive care including rehabilitation and/or lifestyle modifications.

Preventive/Maintenance Care: Elective health care that is typically long-term, by definition not therapeutically necessary but is provided at preferably regular intervals to prevent disease, prolong life, promote health and enhance the quality of life. This care may be provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent future problems. This care may incorporate screening/evaluation procedures designed to identify developing risks or problems that may pertain to the patient's health status and give care/advice for these. Preventive/maintenance care is provided to optimize a patient's health. Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur.

Various manipulative/adjustment techniques may be employed by doctors of chiropractic, and practitioners may vary in the approaches utilized. The term "spinal manipulation" refers to all types of manual techniques. While many techniques are taught both in and outside the established curriculum, the most widely taught techniques include the following: 

• Diversified: This is the most commonly used of all techniques and employs a high-velocity, low- amplitude thrust that usually results in cavitation of a joint.
• Extremity manipulation/adjusting: This application is used for joints other than the spine, such as the shoulder, elbow, wrist, hand, finger, hip, knee, etc., and may be used for carpal tunnel syndrome, gait or posture-related problems. 
•  Activator methods: This employs the use of a hand-held spring-loaded instrument-based manipulation/adjustment protocol. Force is generated by the appliance (e.g., Activator Adjusting Instrument [Activator Methods International, Ltd., Phoenix, AZ]; AcuWave [Sigma Instruments, Inc. Cranberry, PA]) and can be used as a primary treatment method for all patients.
• Gonstead: This technique is a variation of the Diversified technique and utilizes manipulation/ adjustment by hand that results in joint cavitation, and may use radiograph analysis, palpation, and temperature gradient studies to determine which segments to manipulate.
• Cox flexion distraction: This technique employs the use of mechanical and hands-on manipulation/adjustment by utilizing a special table where traction is applied to the spine and the spine is flexed forward. This technique requires active participation from the physician and is not primarily mechanical and provider passive such as with mechanical traction or a traction table. It is primarily used to treat disc herniation, non-disc spinal disorders, and to increase mobility of the spinal joints.
• Thompson: This is also a variation of the Diversified technique using a table with several segments called drop pieces. The drop pieces assist the thrust while minimizing the force used for the manipulation/adjustment.

Provider Record Keeping Requirements for Chiropractic Manipulative Treatments

General Requirements

Chiropractors must maintain medical records which comport with the record keeping standards of the chiropractic profession. However, to the extent the chiropractic profession’s record keeping standards do not already require it, for a chiropractor to be reimbursed for claims for chiropractic manipulative treatments (CPT Codes 98940 through 98943), the medical records he or she creates and maintains for his patients must also comply with the following requirements:  

1. The date and the patient’s name must appear on each page of the medical record.
2. Each patient encounter must be a separate record. 
3. The patient’s entire record must be legible (i.e., must be legible to someone other than the writer).
4. Entries in the medical record must be made within a week of the chiropractor performing the chiropractic manipulative treatments.
5. The medical record must demonstrate that the chiropractic manipulative treatments are medically necessary.
6. The medical records must demonstrate that the patient’s treatment plan is consistent with his or her diagnoses.
7. CPT codes and ICD codes reported on claim forms or billing statements are supported by the documentation in the medical record.
8. The chiropractor must provide a definition sheet of abbreviations specific to his or her office to assist BCBSSC in interpreting patients’ medical records. 

Documentation corrections should be single line drawn through the error with the corrected text in close proximity, initialed and dated by the person who made the error. 

Treatment Notes/Patient Encounter Notes

In addition, to the extent the chiropractic profession’s record keeping standards do not already require it, for a chiropractor to be reimbursed for claims for chiropractic manipulative treatments, the following information must be recorded by the chiropractor in each individual record of a patient encounter. 

  A. Initial Visit: The following information must be included in a patient’s medical record for the patient’s initial visit: 

1. A patient history. The patient history must contain a description of: 

• The symptoms causing the patient to seek treatment.
• The patient’s family history, if relevant.
• The patient’s past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history).

      2. A description of the present illness, including: 

• The mechanism of trauma.
• The quality and character of the patient’s symptoms/problem(s).
• The onset, duration, intensity, frequency, location, and radiation of symptoms.
• Any aggravating or relieving factors.
• Any prior interventions, treatments, medications, secondary complaints.
• The symptoms causing patient to seek treatment — These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine, muscle, bone, rib and joint and be reported as pain, inflammation, or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement in the patient’s medical record that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined. 

      3. An evaluation of the musculoskeletal/nervous system through physical examination. 

      4. Diagnosis. 

      5. Treatment Plan: The treatment plan must include the following: 

• The recommended level of care (duration and frequency of visits)
• The specific treatment goals
• The objective measures to be used to evaluate treatment effectiveness 

      6. A description of the treatment given on the patient’s initial visit, if any. 

      7. The legible signature and professional identification of the individual who furnished the chiropractic manipulative treatments.

  B. Subsequent Visits: The following information must be included in a patient’s medical record for the patient’s subsequent visits:

        1. A patient history

• Review of chief complaint, which should include the date of initial treatment or date of exacerbation of the existing condition
• Changes since last visit
• System review, if relevant

        2. A physical examination of the patient, which includes:

• An exam of the area of the spine involved in the diagnosis.
• An assessment of the change in the patient’s condition since his/her last visit.
• An evaluation of the effectiveness of the patient’s treatment(s).

        3. A description of the treatment given.

        4. The legible signature and professional identification of the individual who furnished the chiropractic manipulative treatments. 

REMINDER:
BlueCross BlueShield of South Carolina does not recognize incident-to billing but requires that claims be billed under the name of the provider who actually rendered the service(s), including chiropractic manipulative treatments.

Provider Record Keeping Requirements for Modalities and Therapeutic Procedures

Definitions
Modality/Modalities: Current Procedural Terminology ("CPT") Codes 97010 through 97039. 

Therapeutic Procedures: CPT Codes 97110 through 97564. 

Timed Codes: Those Modalities and Therapeutic Procedures that contain the phrase "each 15 minutes" in their code descriptors. For example, CPT Code 97110 is a timed code. The descriptor for CPT Code 97110 reads "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 

General Requirements

Providers must maintain medical records which comport with the record keeping standards of their profession. However, to the extent the provider’s profession’s record keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, his or her medical records must also comply with the following requirements: 

1. The date and the patient’s name must appear on each page of the patient’s medical records.
2. Each patient encounter must be a separate record.
3. The patient’s entire record must be legible (i.e., must be legible to someone other than the writer).
4. Entries in the medical record must be made within a week of the provider performing the modalities and/or therapeutic procedures.
5. The medical record must demonstrate that the modalities and/or therapeutic procedures are medically necessary.
6. The medical records must demonstrate that the patient’s treatment plan is consistent with his or her diagnoses.
7. CPT codes and ICD codes reported on claim forms or billing statements are supported by the documentation in the medical record.
8. The provider must provide a definition sheet of abbreviations specific to his or her office to assist BlueCross in interpreting patients’ medical records.
9. Documentation corrections should be single line drawn through the error with the corrected text in close proximity, initialed and dated by the person who made the error.

Treatment Notes/Patient Encounter Notes

In addition, to the extent the provider’s profession’s record keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, the following information must be recorded by the provider in each individual record of a patient encounter:

1. A description, not a reiteration of the CPT Code, of each individual modality and therapeutic procedure provided and billed in language that can be compared with the billing on the claim to verify correct coding
2. For timed codes, an indication of the total number of minutes each individual modality and therapeutic procedure was performed
3. A description of the specific area of the patient’s body to which each individual modality and therapeutic procedure was directed and/or performed
4. The legible signature and professional identification of the individual who furnished each individual modality and therapeutic procedure
5. The patient’s response to the treatment
6. A skilled ongoing reassessment of the patient’s progress toward treatment goals
7. A description of the patient’s progress toward the goals in objective, measurable terms using consistent and comparable methods
8. A description of any patient problems or changes to the plan of care
9. A description of the reason for the encounter
10. A date for a return visit or follow-up plan

REMINDER:

BlueCross BlueShield of South Carolina does not recognize incident-to billing, but requires that claims be billed under the name of the provider who actually rendered the service, modality or therapeutic procedure.

References:

1. Axen I, et al. The Nordic Back Pain Subpopulation Program: Can Patient Reactions to the First Chiropractic Treatment Predict Early Favorable Treatment Outcome in Persistent Low Back Pain? Journal of Manipulative and Physiological Therapeutics 2002; 25:450-454.
2. Axen I, et al. The Nordic Back Pain Subpopulation Program: Can Patient Reactions to the First Chiropractic Treatment Predict Early Favorable Treatment Outcome in Non-persistent Low Back Pain? Journal of Manipulative and Physiological Therapeutics 2005; 28:153-158.
3. Axen I, et al. The Nordic Back Pain Subpopulation Program: Validation and Improvement of a Predictive Model for Treatment Outcome in Patients With Low Back Pain Receiving Chiropractic Treatment. Journal of Manipulative and Physiological Therapeutics 2005b; 28:381-5.
4. CMS Manual System: Pub. 100-02. Medicare Benefit Policy. Transmittal 23; rev. October 2004: 2007.
5. Centers for Medicare & Medicaid Services. Palmetto GBA (01302) LCD Chiropractic Services (L28249) Effective September 02, 2008. Updated December 17, 2009. Accessed March 2010.
6. Ernst E. Spinal Manipulation: A Systematic Review of Sham-controlled, Double Blind, Clinical Trials. Journal of Pain and Symptom Management 2001; 22:879-889.
7. Ernst E. Chiropractic Manipulation for Non-spinal Pain: A Systematic Review. New Zealand Medical Journal 2003; 116:U539.
8. Green CJ, Martin C, Bassett K, et al. Systematic Review of Craniosacral Therapy: Biological Plausibility, Assessment Reliability and Clinical Effectiveness. Complementary Therapies in Medicine. 1999;7(4):201-7.
9. Hurwitz EL, et al. A Randomized Trial of Medical Care With and Without Physical Therapy and Chiropractic Care With and Without Modalities for Patients With Low Back Pain: 6-Month Follow-Up Outcomes From the UCLA Low Back Pain Study. Spine 2002a; 27:2193-2204.
10. Hurwitz EL, et al. The Effectiveness of Physical Modalities Among Patients With Low Back Pain Randomized to Chiropractic Care: Findings From the UCLA Low Back Pain Study. Journal of Manipulative and Physiological Therapeutics 2002b; 25:10-20.
11. Activator Methods, International Ltd. Activator Methods. © Copyright 1995-2002 Activator Methods. Accessed December 7, 2011.
12. Agency for Healthcare Research and Quality (AHRQ) (previously Agency for Healthcare Policy and Research [AHCPR]). Chiropractic in the United States: training, practice and research. Publication No. 98-N002. 1997 Dec.
13. American Chiropractic College of Radiology (ACCR). ACCR guideline on computer assisted mensuration for postural analysis of radiographs. 2004.
14. American College of Radiology (ACR). ACR Practice Guideline for Performing and Interpreting Diagnostic Ultrasound Examinations. Effective 10/01/2006.
15. American Institute of Ultrasound Medicine (AIUM). AIUM Practice Guideline for the Performance of Musculoskeletal Ultrasound Examination. © 2007 by the American Institute of Ultrasound Medicine. Effective October 1, 2007.
16. American Institute of Ultrasound Medicine (AIUM).Nonoperative spinal/paraspinal ultrasound in adults. Approved June 2002.
17. Farabaugh RJ, Dehen MD, Hawk C. Management of chronic spine-related conditions: consensus recommendations of a multidisciplinary panel. Council of Chiropractic Guidelines and Practice Parameters (CCGPP). J Manipulative Physiol Ther. 2010 Sep;33(7):484-92. Epub 2010 Aug 25.
18. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Manual therapy for asthma. Cochrane Database of Systematic Reviews 2005, Issue 2. Copyright © 2006 The Cochrane Collaboration.
19. Kijowski R, De Smet AA. The role of ultrasound in the evaluation of sports medicine injuries of the upper extremity. Clin Sports Med. 2006 Jul;25(3):569-90,viii.
20. Kohlbeck FJ, Haldeman S. Technology assessment: medication assisted spinal manipulation. Spine J. 2002 Jul-Aug;2(4):288-302.
21. Rubinstein SM. Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks? J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):461-4.
22. Taylor SH, Arnold ND, Biggs L, Colloca CJ, Mierau DR, Symons BP, Triano JJ. A review of the literature pertaining to the efficacy, safety, educational requirements, uses and usage of mechanical adjusting devices: Part 1 of 2. JCCA J Can Chiropr Assoc. 2004 Mar;48(1):74-108.
23. Taylor SH, Arnold ND, Biggs L, Colloca CJ, Mierau DR, Symons BP, Triano JJ. A review of the literature pertaining to the efficacy, safety, educational requirements, uses and usage of mechanical adjusting devices: Part 2 of 2. JCCA J Can Chiropr Assoc. 2004 Jun;48(2):152-61.
24. Bronfort, G. Spinal Manipulation: current stat of research and its indications. Neurologic Clinics. February 1999;17(1):92-111
25. Sawyer ZCE, Evans RL, Boline PD, et al. A feasibility study of chiropractic spinal manipulation versus sham spinal manipulation for chronic otitis media with effusion in children. J Manipulative Physiol Ther. 1999;22(5):292-298.
26. Hughes S, Bolton J. Is chiropractic an effective treatment in infantile colic? Arch Dis Child. 2002;86(5):382-384.
27. Ernst E. Serious adverse effects of unconventional therapies for children and adolescents: A systematic review of recent evidence. Eur J Pediatr. 2003;162(2):72-80.
28. Olafsdottir E, Forschei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child. 2001;84:138-141.
29. Kilgour T, Wade S. Infantile colic. In: Clinical Evidence. London, UK: BMJ Publishing Group; September 2004.
30. Ricotti V, Delanty N. Use of complementary and alternative medicine in epilepsy. Curr Neurol Neurosci Rep. 2006;6(4):347-353.
31. Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2006;(3):CD002119.
32. Everett CR, Patel RK. A systematic literature review of nonsurgical treatment in adult scoliosis. Spine. 2007;32(19 Suppl):S130-S134.
33. McElroy-Cox C. Alternative approaches to epilepsy treatment. Curr Neurol Neurosci Rep. 2009;9(4):313-318.
34. Ferrance RJ, Miller J. Chiropractic diagnosis and management of non-musculoskeletal conditions in children and adolescents. Chiropr Osteopat. 2010;18:14.
35. Ohm J. About the Webster protocol. International Chiropractic Pediatric Association. ICPA: Media, PA. 2006. Available at: http://icpa4kids.com/about/webster_technique.htm. Accessed January 13, 2012.
36. Cohain JS. Turning breech babies after 34 weeks: The if, how, & when of turning breech babies. Midwifery Today Int Midwife. 2007;(83):18-19, 65.
37. Ernst E. Chiropractic spinal manipulation for infant colic: A systematic review of randomised clinical trials. Int J Clin Pract. 2009;63(9):1351-1353.
38. Ernst E. Chiropractic treatment for gastrointestinal problems: A systematic review of clinical trials. Can J Gastroenterol. 2011;25(1):39-40.
39. No authors listed. Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11):1155-1172; quiz 1173-1174.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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