CPT® Procedure Codes
HCPCS Supply/DME Codes
ICD-9-CM Diagnosis Codes
DRGs & APCs
ICD-10-CM Diagnosis Codes
ICD-10-PCS Procedure Codes
Place of Service Codes
UB04 Condition Codes
UB04 Revenue Codes
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.
Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient's symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient's clinical presentation. Failure of the patient's symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.
This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per month and 30 chiropractic manipulation services per beneficiary per year. Despite allowing up to these maximums, each patient's condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient's medical record.
Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for chiropractic services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for chiropractic services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding chiropractic services are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- Medicare Benefit Policy Manual - Pub. 100-2, Chapter 15, Section 30.5, Section 240.1.3.
- Medicare National Coverage Determinations Manual - Pub. 100-03.
- Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-09, Chapter 5.
- Social Security Act (Title XVIII) Standard References, Sections:
- 1862 (a)(1)(A) Medically Reasonable & Necessary.
- 1862 (a)(1)(D) Investigational or Experimental.
- 1833 (e) Incomplete Claim.
Jurisdiction "H" Notice:
Jurisdiction "H" comprises the states of Arkansas, Louisiana, Mississippi, Colorado, New Mexico, Oklahoma, and Texas. Novitas is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (8/13/2012 - 11/19/2012); and, is a consolidation of the previous legacy contractors' policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination.
ST Legacy A
J "H" MAC A
J "H" MAC B
AR PBSI: 00520 (J7) Novitas: 07102 08/13/12 LA PBSI: 00528 (J7) Novitas: 07202 08/13/12 AR PBSI: 00020 (J7) Novitas: 07101 08/20/12 LA PBSI: 00233 (J7) Novitas: 07201 08/20/12 MS PBSI: 00233 (J7) Novitas: 07301 08/20/12 MS Cahaba: 00512 (J7) Novitas: 07302 10/22/12 J 4
Trailblazer: 04901 Novitas: 04911 10/29/12 CO Trailblazer: 04101 Novitas: 04111 10/29/12 NM Trailblazer: 04201 Novitas: 04211 10/29/12 OK Trailblazer: 04301 Novitas: 04311 10/29/12 TX Trailblazer: 04401 Novitas: 04411 10/29/12 CO Trailblazer: 04102 Novitas: 04112 11/19/12 NM Trailblazer: 04202 Novitas: 04212 11/19/12 OK Trailblazer: 04302 Novitas: 04312 11/19/12 TX Trailblazer: 04402 Novitas: 04412 11/19/12
Contractor Name(Contractor Number) - Contractor Info
OIG Reports and Instructions:
OIG Report OEI-07-07-00390, Inappropriate Medicare Payments For Chiropractic Services; Published May 2009.
Other Local Coverage Determinations
"Chiropractic Services," TrailBlazer LCD, 4N-6B (L26631)
Novitas Solutions, Inc. - JH Local Coverage Determination (LCD) Consolidation
Narrative Justification - Most Clinically Appropriate LCD
L30295, Chiropractic Services, TrailBlazer - IV - CO, NM, OK, TX - B
L11919, Chiropractic Service (Manual Spinal Manipulation), Pinnacle - VI - LA
L8177, Chiropractic Service (Manual Spinal Manipulation), Pinnacle - VI - AK
DL32351, Medicine: Chiropractic Services (not considered d/t draft status), Cahaba - MS
The TrailBlazer LCD imposes limits per month and per year and the Pinnacle LCD does not. The LCD from Pinnacle has additional information in the section titled Chiropractic Treatment Guidelines. All LCDs have similar codes. The TrailBlazer LCD Sources of Information and Basis for Decision includes the OIG Report and another TrailBlazer LCD. TrailBlazer LCD is chosen as there are limits on the number of treatments per beneficiary.
L30295 is the most clinically appropriate LCD.
Advisory Committee Meeting Notes
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
The CPT/HCPCS codes included in this LCD will be subjected to "procedure to diagnosis" editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:
Primary Diagnosis Codes
739.0 739.1 739.2 739.3 739.4 739.5 Secondary Diagnosis Codes
Group A Diagnoses
307.81 719.48 723.1 724.1 724.2 724.5 724.8 728.85 784.0 Group B Diagnoses
720.1 721.0 721.1 721.2 721.6 721.90 721.91 724.79 729.1 729.4 846.0 846.1 846.2 846.3 846.8 847.0 847.1 847.2 847.3 847.4 Group C Diagnoses
353.0 353.1 353.2 353.3 353.4 353.8 722.91 722.92 722.93 723.0 723.2 723.3 723.4 723.5 Group D Diagnoses
721.3 721.41 721.42 721.7 722.0 722.10 722.11 722.4 722.51 722.52 722.6 722.81 722.82 722.83 724.01 724.02 724.03 724.3 724.4 724.6 738.4 756.11 756.12 839.01 839.02 839.03 839.04 839.05 839.06 839.07 839.08 839.20 839.21 839.41 839.42 953.0 953.1 953.2 953.3 953.4
Medicare Policies and Guidelines - NCD, LCD, Articles, LMRP
Summary: Medicare Policies and Guidelines - NCD, LCD, Articles, LMRP
Keywords: Medicare Policies and Guidelines, NCD, LCD, LMRP, national coverage determinations, local coverage determinations, local medical review policies
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