98942
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.94
Facility
$38.08
Non-Facility
$49.77
Documentation Required
- Claims must report the precise level(s) of subluxation as the primary diagnosis and the neuromusculoskeletal condition necessitating treatment as the secondary diagnosis.
- Each claim must include date of initiation of the course of treatment, symptom/secondary diagnosis code(s), subluxation/primary diagnosis code(s), date of service, place of service, and procedure code; missing items may cause denial or delay.
- Diagnosis codes supporting medical necessity must be submitted with each claim; progress notes need not accompany each claim but must be maintained and available upon request.
- Chiropractor must file the claim, and when providing active/corrective treatment they must append the AT modifier; if provider believes service is likely to be denied, an Advance Beneficiary Notification (ABN) must be obtained and the GA modifier used.
Key Coverage Criteria
- Medicare covers manual manipulation of the spine (chiropractic manipulative treatment) for treatment of spinal subluxation using CPT codes 98940, 98941, or 98942 when medically necessary.
- Subluxation must be demonstrated and documented (by x-ray or physician/chiropractic exam) with the problem/complaint addressed and the precise level of each subluxation treated specified in the medical record.
- Active/corrective treatment for acute or chronic subluxation requires use of the AT modifier on claims.
- Clinical findings supporting subluxation should follow PART elements (Pain, Asymmetry/misalignment, Range of motion abnormality, Tissue/tone changes) documented by observation, palpation, imaging, or measurement as appropriate.
- Chiropractic manipulation is covered when provided as active/corrective treatment to treat an acute or chronic vertebral subluxation and the claim includes the AT modifier.
- A manipulation claim is covered when the chiropractor documents precise level(s) of the subluxation for each spinal region treated to substantiate the service.
14 Active Policies
A57889 — Chiropractic Services Medical Policy Article
J06
A58412 — Billing and Coding: Chiropractic Services
J09
A58345 — Billing and Coding: Chiropractic Services
J12
A56616 — Billing and Coding: Chiropractic Services
A57913 — Billing and Coding: Chiropractor Services
Related Codes
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