11 Chiropractic Medicine

IMPORTANT

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 the fees authorized in this schedule, then the usual and customary fees must be used. Managed Care Organizations which comply with North Carolina law and the 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. Gen. Stat. 97-2(20) and 97-88.2.

2. Pursuant to Rule 802 of the Workers Compensation Rules of the North Carolina Industrial Commission, any employer, carrier or third party administrator who routinely denies chiropractic treatment as a matter of policy may be subject to sanctions by the Industrial Commission.

3.When an injured employee has reported the injury to his or her employer and the employer has not made a direct referral to a physician, the employee may go to the physician of his or her choice. N.C. Gen. Stat. 97-25.

4. When a chiropractic physician is the initial treating physician, either through direct employer referral or under circumstances described in Paragraph 3 above, an authorization-to-treat slip is NOT required.

5. A chiropractic physician may treat an injured worker for up to 20 visits without further authorization.

6. When more than 20 visits are necessary, the chiropractic physician must obtain authorization for additional visits from the payor, i.e., the self-insured employer, the insurance company or the third party administrator.

7. When an injured employee has been treated by a physician and wishes to be treated by a different physician, who may or may not be a chiropractic physician, he or she has the right to request treatment by a physician (chiropractic or otherwise) of his or her choice and should contact the employer or write to the Industrial Commission to obtain permission. N.C. Gen. Stat. 97-25.

8. An employer can request that an injured employee seek evaluation by another physician, but the injured employee may continue treatment with the chiropractic physician for up to the initial 20 visits. N.C. Gen. Stat. 97-27.

9. An employer, insurance company, or third party administrator may not unilaterally terminate a patient's chiropractic treatment during the initial 20 visits.

10. Except for the number of visits for the initial 20 visits, visits to a chiropractic physician are subject to Utilization Review.

GUIDELINES

Chiropractic medicine may be an integral part of the healing process for some injured workers. 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. Chiropractic physicians must meet the following requirements in order to be paid under this fee schedule:

A. CHIROPRACTIC MEDICAL ASSESSMENT

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

c. The estimated duration of the treatment regimen

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

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 payor. 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 payor.

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 payor for continuing care. Treatment must meet the following guidelines:

a. The treatment must tend to effect a cure, give relief, or lessen the period of disability.

b. When approval to treat is given by telephone, documentation should be made by the provider in the patient's medical record indicating the date and name of the payor representative giving authorization for the 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 be reimbursed as billed in units of 15 minutes. Appropriate rounding up or down is expected, using professional judgment. Billing for excessive 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) treatment may be provided either by the chiropractic physician or under his supervision.

2. Authorization, including selection of the vendor, must be obtained from the payor before rental of a TENS unit or before arrangements are made for the purchase of a TENS unit at a price in excess of $250.

F. SUPPLIES and EQUIPMENT

1. Chiropractic physicians must obtain authorization from the payor before purchase or rental of durable medical equipment in excess of $100.

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.

3. Reimbursement for vitamins, herbs and nutritional supplements is not allowed under this fee schedule.

G. OTHER INSTRUCTIONS

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

2. All charges for services must be clearly itemized by CPT code. The Federal tax ID number or chiropractor’s social security number must be on the bill. Billing is also subject to all medical billing directives of the Industrial Commission.

Chiropractors may use the following CPT Evaluation and Management codes:

CPT Code Description Allowance
99201 New patient, 10 min $41.40
99202 New patient, 20 min $66.68
99203 New patient, 30 min $91.97
99204 New patient, 45 min $137.97
99211* Established patient, 5 min $20.11
99212* Established patient, 10 min $36.21
99213* Established patient, 15 min $51.16
99372 Telephone call by chiropractor to patient, rehabilitation professional, physician, or any other medical provider or medical coordinator, 15 to 30 minutes $45.00
99373 Telephone call by chiropractor to patient, rehabilitation professional, physician, or any other medical provider or medical coordinator, more than 30 minutes $60.00
99455 Rating by treating physician $125.31
99456 Rating by other than treating physician $182.13
99052 After Hour Services between 10 p.m. and 8 a.m. (in addition to regular billing) $26.26

to be used only in exceptional circumstances.

* may be used only under one of the four cases outlined in D4 above.

 

Chiropractors may use the following CPT codes for chiropractic manipulation:

CPT Code Description Allowance
98940 Chiropractic manipulative treatment(CMT); spinal, one to two regions $35.83
98941 spinal, three to four regions $45.36
98942 spinal, five regions $55.80
98943 extraspinal, one or more regions $32.95

 

Chiropractors may use the following Physical Medicine CPT codes:

SUPERVISED

CPT Code Description Allowance
97010 Hot or cold pack modality (includes pack in chg) $13.95
97012 Mechanical traction $18.90
97014 Electrical stimulation, unattended $16.20
97024 Diathermy $13.95
97026 Infrared $13.05
97028 Ultraviolet $16.65
CONSTANT ATTENDANCE
97032 Elec. stimulation, constant attendance, each 15 min $16.65 times # of units
97033 Iontophoresis, each 15 min $17.55 times # of units
97035 Ultrasound, each 15 min $13.95 times # of units
97110 Therapeutic exercises, each 15 min $25.19 times # of units
97124 Massage, each 15 min $19.80 times # of units
97140 Manual treatment, each 15 min (myofascial release) $26.79 times # of units

 

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

Chiropractors may use the radiology codes found in the Workers’ Compensation Medical Fee Schedule radiology section that are considered within their scope of practice.

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


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