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18.3 Benefits and Limitations
Medicaid reimburses the treatment of a spinal subluxation by manual manipulation of the spine. The exact level of subluxation must be indicated by the appropriate International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis code listed in the following table or narrative. Chiropractors are not required to certify that an X-ray is available to demonstrate the existence of a subluxation. However, chiropractors may use an X-ray for this purpose.
The following guidelines apply when documenting a subluxation by X-ray:
• An acute condition is documented by an X-ray taken no more than three months before the date treatment is initiated.
•A chronic condition is documented by an X-ray taken no more than 12 months before the initiation of treatment.
•An older X-ray may be used if the subluxation has existed for more than 12 months and is considered a chronic and permanent condition.
The following diagnosis codes are accepted in lieu of written documentation to indicate treatment and level of subluxation:
Medicaid does not reimburse chiropractors for X-ray services, office visits, injections, supplies, appliances, spinalator treatments, laboratory services, physical therapy, or other adjunctive services furnished by the chiropractors themselves or by others under their orders or directions.
Coverage includes up to 12 treatments per benefit period. For chiropractic services, the Texas Medicaid Program defines a benefit period as "12 consecutive months, beginning with the date the client receives the first Medicaid-covered chiropractic treatment." Benefits cannot exceed one treatment per day.
Coverage is limited to the following procedure codes:
The AT modifier is required when billing for acute and chronic conditions to identify acute chiropractic manipulative treatment (CMT) services.
Qualified Medicare Beneficiary (QMB) and Medicaid Qualified Medicare Beneficiary (MQMB) clients are excluded from chiropractic limitations. When chiropractic services are submitted for these clients, the service is denied with instructions to bill Medicare first.
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