Medicaid 101 Chiropractic Services HHWHIPP 0518 1017 Providing

Medicaid 101 Chiropractic Services HHW-HIPP 0518 (10/17) Providing health coverage to Indiana families since 1994

Agenda • • 2 Introduction Services that can be rendered by a Chiropractor Self-referred Chiropractic services Therapy services rendered by a Chiropractor Coverage and Reimbursement for Chiropractic services Authorization Requirements Claims Submission Questions

Introduction • The Indiana Health Coverage Programs (IHCP) provides reimbursement for covered chiropractic services for members when the services are provided by a licensed chiropractor. • Services such as office visits, physical medicine treatments, laboratory, x-ray, and muscle testing are available to all IHCP members, pursuant to restrictions outlined in the individual’s benefit package, when necessitated by a condition-related diagnosis. 3

Services that can be rendered by a Chiropractor • The IHCP limits claim payment for chiropractic practitioners (specialty 150) to certain Current Procedural Terminology (CPT® 1) procedure codes. • IHCP also requires that chiropractic services be billed with certain International Classification of Diseases (ICD) codes as the principal diagnosis. 4

Services that can be rendered by a Chiropractor • The Chiropractic Services Codes document on the Code Sets page at indianamedicaid. com identifies the CPT codes that chiropractors should bill to the IHCP for office visits, manipulative treatment, radiology, physical medicine services, as well as the appropriate principal diagnosis codes for billing chiropractic services to the IHCP. • http: //provider. indianamedicaid. com/ihcp/Publications/pro vider. Codes/Chiropractic_Services_Codes. pdf 5

Self-referred Chiropractic services Self-referred Services • Self-referral services do not require a referral from a member’s PMP • Self-referral services for chiropractors include the following: o Office visits o Manipulations o X-rays o Laboratory tests that fall within chiropractic scope of practice 6

Self-referred Chiropractic services • Self-referred chiropractic services are covered under the following benefit packages: o Hoosier Healthwise o Healthy Indiana Plan State Plan Plus o Healthy Indiana Plan State Plan Basic o Healthy Indiana Plan Maternity • Self-referred chiropractic services are not covered under the following benefit packages: o Healthy Indiana Plan Basic o Healthy Indiana Plan Plus § Healthy Indiana Plan Plus package will begin to offer 6 self-referral chiro visits beginning January 1, 2018 7

Therapy services rendered by a Chiropractor Therapy Services • Chiropractors are able render covered therapeutic procedures outlined in the Chiropractic Services Codes document if the appropriate authorization is obtained based on the members assigned program. • Examples of covered therapy codes include: o 98940 -98943, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97034 -97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140 o http: //provider. indianamedicaid. com/ihcp/Publications/pr ovider. Codes/Chiropractic_Services_Codes. pdf 8

Therapy services rendered by a Chiropractor • Therapy services rendered by chiropractors are covered under all of the following benefit packages: o Hoosier Healthwise o Healthy Indiana Plan State Plan Plus o Healthy Indiana Plan State Plan Basic o Healthy Indiana Plan Maternity o Healthy Indiana Plan Basic o Healthy Indiana Plan Plus 9

Coverage and Reimbursement for Chiropractic services • The IHCP limits reimbursement for chiropractic services to a total of 50 units per member per calendar year. The 50 units can be a combination of office visits, spinal manipulation, or physical medicine treatments. • IHCP limits office visits to five per year; that is, up to five of the 50 units can be office visits. • New patient office visits are reimbursed once per lifetime, per member, per provider, (or once per three-year period, for a provider of the same specialty and in the same practice). 10

Coverage and Reimbursement for Chiropractic services • Reimbursement is not available for the following types of extended or comprehensive office visits: o New patient detailed o New patient comprehensive o Established patient detailed o Established patient comprehensive • An office visit code is reportable on the same date as a manipulative treatment only if the visit constitutes a significant, separately identifiable evaluation and management (E/M) service. 11

Coverage and Reimbursement for Chiropractic services • Reimbursement is not available for durable medical equipment (DME) provided by chiropractors. • Reimbursement for x-rays is limited to one series of full spine x-rays per member per year. Component x-rays of the series are individually reimbursable; however, if components are billed separately, total reimbursement is limited to the allowable amount for the series. • Chiropractors may perform laboratory tests that fall within their scope of practice for the state of Indiana. These tests include performance of blood analysis and urinalysis. 12

Authorization Requirements • Providers must check the appropriate program’s prior authorization list to verify if these covered services require an authorization or not. o To find this information providers will go to MDwise. org > For Providers > Forms > Prior Authorization Forms o http: //www. mdwise. org/for-providers/forms/priorauthorization/ 13

Authorization Requirements • Each delivery system has their own prior authorization list for Hoosier Healthwise. o Provider's must verify which delivery system the member belongs to validate if an authorization is required or not for the service. • Healthy Indiana Plan (HIP) has the same prior authorization guidelines for all the delivery systems. • Prior authorization is not required for out of network chiropractic services except if service is otherwise listed on PA list. 14

Claims Submission Claim Submission • Contracted providers must submit claims to MDwise within 90 days of the date of rendering the service • When MDwise is the secondary payer, please submit claims within 90 days of the date of the primary explanation of benefits (EOB) Corrected Claims or Resubmissions • Should be submitted electronically • MDwise adheres to NUCC and NUBC guidelines; claims stamped or denoted as corrected will not be recognized • MDwise utilizes final value of bill type on UB claims (Claim Frequency Code) and the Resubmission Code (Box 22) value on the CMS 1500 15

Claims Submission *Hoosier Healthwise claims for the St. Catherine, Select Health and St. Vincent delivery systems go to a separate address and payer ID. This information can be located in the MDwise quick contact guide. * 16

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