Note: Priority Health Medicare Advantage plans follow Medicare coverage and billing rules.
Manipulative treatment or therapy is hands-on-care that involves using the hands to diagnose, treat, and prevent illness or injury. The treatment involves movement of muscles and joints using techniques including stretching, gently pressure and resistance. The treatment may be used to treat muscle pain and other disorders, promote healing and increase overall mobility. - American Osteopathic Association
Coverage for manipulationsPriority Health offers many different types of benefit plans. Some include the manipulation benefit under short-term rehabilitative coverage, which means all services, including physical and occupational therapy, biofeedback and manipulation, count to the same benefit limit.
- Before treatment, verify if a patient has exhausted his/her short-term rehabilitative benefits by calling the Provider Helpline.
- Benefits renew annually on the patient's contract renewal date, which may or may not be January 1.
- Also see the section on billing for physical therapy in this Manual.
Only one provider should bill for a written interpretation of the X-ray. If you are only reviewing what the radiologist or other physician has interpreted, do not bill for this service.
If a provider does both the technical and professional components of a procedure, the procedure code should be billed without a modifier to show it is a global service.
- AT modifier: See Chiropractic manipulative treatment billing, below.
- TC modifier: If the X-rays are taken in the office and interpreted by another provider outside your practice, append the modifier TC (technical component) to the procedure code.
- 26 modifier: If the X-rays are taken by another provider and you provide the written interpretation, append the modifier 26 (professional component) to the procedure code.
Chiropractic manipulative treatment billing
Priority Health follows national standards for documentation and billing of these services. Reference the documentation guidelines above.
Chiropractic treatment codes include a pre-manipulation patient assessment. Priority Health recognizes that an additional evaluation and management service may be needed if the patient's condition requires a significant separately identifiable E&M service above and beyond the usual pre- and post-service work associated with the chiropractic service. The medical record documentation needs to support all procedure codes billed.
Also see: Billing & payment > Modifiers > AT modifier
The American Chiropractic Association states, in article titled "Coding Misuse Prompts Fraud Investigations":
Billing an Evaluation and Management (E/M) Code on Every Visit with CMT: In general, it is inappropriate to bill an established office/outpatient E/M code (99211-99215) on the same visit as Chiropractic Manipulative Treatment (98940-98943) because CMT codes already include a brief pre-manipulation assessment. There are times when it would be appropriate, but it should not be routine.
Examples of when it may be appropriate to bill an additional E/M service would be the evaluation of new patients, new injuries, exacerbations, or periodic re-evaluations. If you are being told that billing an E/M code on every visit is a proper form of billing, it is incorrect. Refer to the American Chiropractic Association (ACA) website www.acatoday.org, Insurance and Reimbursement, for specific guidance on the proper use of E/M with a Chiropractic Manipulative Treatment Code (CMT).
- Read the complete ACA article, "Coding Misuse Prompts Fraud Investigations"
- Visit the American Chiropractic Association website: www.acatoday.org
- Read the ACA Commentary on the Centers for Medicare and Medicaid Services Clinical Documentation Guidelines
Osteopathic services billing
Priority Health follows national standards for documentation and billing osteopathic manipulative treatment services.
- E&M services may be reported separately, using modifier 25 if the patient's condition requires a significant separately identifiable E&M service above and beyond the usual pre- and post-treatment service.
- The E&M service may be for the same conditions for which the OMT is provided, so it may be billed with the same diagnosis.
- The documentation should clearly distinguish the services that support the E&M service and the OMT service.
- E&M service is not warranted for planned follow-up treatments unless the patient presents with a new condition, change or lack of improvement in condition that necessitates an overall reassessment.
- Billing must be supported by Priority Health documentation requirements.
- LCD for Osteopathic Manipulative Treatment (L3206) on the CMS website (you may have to accept the license agreement first)
- American Academy of Osteopathy series on use of the SOAP note to record data on patient encounters to support research on osteopathic principles and practices