11 Chiropractic Medicine

The fees set forth herein are those which are the maximum allowed to be charged for treatment of injured workers under the North Carolina Workers’ Compensation Act. If the usual and customary fees are less than this schedule, then the usual and customary fees must be used. Managed Care Organizations which comply with North Carolina law and the States Rules and Regulations for Managed Care Organizations are not subject to the Medical Fee Schedule.

The following principles apply to workers’ compensation and chiropractic care:

1. Chiropractic care IS covered under the Workers’ Compensation Law in North Carolina and it would be false and misleading for an insurance company or its representatives to state or imply otherwise. N.C.G.S.§97-2(20) & §97-88.2

2. When an injured employee has reported the injury to his/her employer, and the employer has not made a direct referral to a physician, the employee may go to the physician of his/her choice. N.C.G.S. §97-25

3. When a chiropractic physician is the initial treating physician, either through direct employer referral, or as defined in number two above, an authorization to treat slip is NOT required.

4. A chiropractic physician has 20 visits allotted to treat a patient.

5. When more than 20 visits are necessary, the chiropractic physician may obtain authorization for additional visits from either the employer or the insurance company.

6. When an injured employee has been treated by a doctor and wishes to be treated by another physician, he or she has the right to request treatment by a physician of his/her choice, and should contact the employer or write to the Industrial Commission to obtain permission. N.C.G.S. §97-25

7. An employer can request than an injured employee seek evaluation by another physician, but the injured employee may continue treatment with the chiropractic physician for the initial 20 visits. N.C.G.S. §97-27

8. An insurance company may not terminate a patient’s chiropractic treatment during the initial 20 visits.

GUIDELINES

Chiropractic medicine is an integral part of the healing process for a variety of injured workers. Recognizing this, this schedule includes codes for chiropractic medicine, i.e., those modalities, procedures, tests, and measurements in the chiropractic medicine section, representing specific therapeutic procedures performed by licensed chiropractors and within their scope of practice, or by support personnel under direct supervision of a licensed chiropractor. The following criteria must be met in all cases where chiropractic medicine is rendered in order for a service to qualify for reimbursement.

A. CHIROPRACTIC MEDICAL ASSESSMENT

1. An assessment, including a plan of care, must be performed to determine if a patient will benefit from chiropractic medicine treatment.

2. When billing for the assessment, plan of care and visit, the chiropractor shall use only one of the appropriate CPT Evaluation and Management codes.

B. QUALIFICATIONS FOR REIMBURSEMENT

1. The patient’s condition must have the potential for restoration of function.

2. The treatment must be specific to the injury and have the potential to improve the patient’s condition.

C. PLAN OF CARE

1. An initial plan of care must be developed and filed with the payer. The content of the plan of care, at a minimum, should contain:

a. The potential degree of restoration and measurable goals (i.e., potential restoration is good, poor, low, guarded)

b. The specific treatments to be provided, including the frequency and duration of each treatment

c. The estimated duration of the treatment regimen

2. Preparation of the initial care plan is included in the initial assessment, plan of care and visit, and no additional fee shall be charged therefor.

3. If treatment beyond the initial 20 visits is authorized, the plan of care must be updated at the end of the initial 20 visits and at least every 30 days thereafter. The updated plan must be signed by the chiropractic physician and submitted to the payer. Charges for this reassessment and updated plan of care shall be billed using the appropriate CPT Evaluation and Management code.

D. REIMBURSEMENT

1. Visits for treatment may not exceed one visit per day without prior approval from the payer.

2. A minimum of an initial visit and 19 subsequent visits is allowed upon initial authorization of chiropractic treatment. Treatment exceeding 20 visits must have preauthorization from the payer for continuing care. It must meet the following guidelines:

a. The treatment must be medically necessary

b. Telephone approval is appropriate. Documentation should be made by the provider in the patient’s medical record indicating the date and name of the payer representative giving authorization for the continued treatment.

3. Physical Medicine Modalities are now divided into two groups: "supervised" and "constant attendance." Supervised modalities will be reimbursed as billed for only one unit per visit. Constant attendance modalities will he reimbursed as billed in units of 15 minutes. Appropriate rounding up or down is expected through professional judgment. Excess in units will be subject to Utilization Review.

4. A chiropractic physician may charge and be reimbursed for a follow-up examination in the following cases:

a. Reassessment as defined in Section C Item 3 (PLAN OF CARE) above

b. A definitive change in the patient’s condition occurs

c. The patient fails to respond to treatment and there is a need to change the treatment plan

d. The patient has completed the treatment regimen and is ready to receive discharge instructions

E. TENS UNITS

1. TENS (Transcutaneous Electrical Nerve Stimulation) may be provided either by the chiropractic physician or under his supervision.

2. Authorization from the payer must he obtained before purchase or rental arrangements are made for TENs. The payer has sole right of selection of vendors for rental or purchase of equipment, supplies, etc.

F. SUPPLIES and EQUIPMENT

1. Chiropractic physicians must obtain authorization from the payer before purchase/rental of durable medical equipment.

2. Reimbursement for supplies and equipment must not exceed 20 percent above the provider’s cost. An invoice may be required by the carrier before reimbursement is made.

G. OTHER INSTRUCTIONS

1. Charges will not be reimbursed for publications, books, or video cassettes unless by prior approval of the payer.

2. All charges for services must be clearly itemized by CPT code. Federal tax ID number or Chiropractor’s Social Security Number must be on the bill.

3. Documentation may he required by the payer to substantiate the necessity for treatment rendered.

Chiropractors may use the following CPT Evaluation and Management codes:

Chiropractors may use the following CPT codes for chiropractic manipulation:

Chiropractors may use the following Physical Medicine CPT codes:

Chiropractors may be reimbursed the regular fee schedule allowance for the following laboratory examination: 81002, urinalysis dipstick, $7.76

Chiropractors may use CPT code 99080 for a narrative report reimbursed up to $165.00. This may be billed when the payer has requested more than the usual information furnished in standard reporting forms.

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