98943
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.45
Facility
$19.37
Non-Facility
$26.39
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.
- Manipulative Therapy is proven and medically necessary for treating Musculoskeletal Disorders.
- Musculoskeletal Disorders (MSDs) are injuries or conditions originating from joints, muscles, ligaments, discs, or other soft tissues in the spine or limbs, and produce clinically relevant symptoms (e.g., pain, numbness, etc.) and functional limitations (e.g., ability to perform daily activities).
9 Active Policies
AMBETTER-CP.BH.124 — Attention Deficit Hyperactivity Disorder Assessment and Treatment
AETNA-CPB-0431 — Enuresis
UHC-POL-manipulative-therapy — Manipulative Therapy
A56273 — Billing and Coding: Chiropractic Services
UMR-POL-UMR-manipulative-therapy — Manipulative Therapy
Related Codes
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