441—78.8 (249A) Chiropractors. Payment will be made for the same chiropractic procedures payable under Title XVIII of the Social Security Act (Medicare).
	   78.8(1) Covered services. Chiropractic manipulative therapy (CMT) eligible for reimbursement is specifically limited by Medicaid to the manual manipulation (i.e., by use of the hands) of the spine for the purpose of correcting a subluxation demonstrated by X-ray. Subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae.
	   78.8(2) Indications and limitations of coverage.
	      a.    	 The subluxation must have resulted in a neuromusculoskeletal condition set forth in the table below for which CMT is appropriate treatment. The symptoms must be directly related to the subluxation that has been diagnosed. The mere statement or diagnosis of “pain” is not sufficient to support the medical necessity of CMT. CMT must have a direct therapeutic relationship to the patient’s condition. No other diagnostic or therapeutic service furnished by a chiropractor is covered under the Medicaid program.
ICD	CATEGORY I	ICD	CATEGORY II	ICD	CATEGORY III	
G44.1	Vascular headache NEC<fo:wrapper font-size=".69em" baseline-shift=".33em">*</fo:wrapper>	G54.0-
G54.4	Nerve root and plexus disorders, brachial plexus disorders, lumbosacral plexus disorders, cervical root disorders NEC, thoracic root disorders NEC, lumbosacral root disorders NEC	M48.30-
M48.33	Traumatic spondylopathy, site unspecified, occipito-atlanto-axial region, cervical region, cervicothoracic region	
G44.209	Tension headache, unspecified, not intractable	G54.8	Other nerve root and plexus disorders	M48.35-
M48.38	Traumatic spondylopathy, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal region	
M47.21-
M47.28	Other spondylosis with radiculopathy, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal region	G54.9	Nerve root and plexus disorder, unspecified	M50.20-
M50.23	Other cervical disc displacement	
M47.811-
M47.818	Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal region	G55	Nerve root and plexus compressions in diseases classified elsewhere	M50.30-
M50.33	Other cervical disc degeneration	

M47.891-
M47.898	Other spondylosis, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal region	M43.00-
M43.28	Spondylolysis; spondylolisthesis; fusion of spine	M51.24-
M51.27	Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacement	
M54.2	Cervicalgia	M43.6	Torticollis	M51.34-
M51.37	Other thoracic, thoracolumbar and lumbosacral intervertebral disc degeneration	
M54.5	Low back pain	M46.00-
M46.09	Spinal enthesopathy	M54.30-
M54.32	Sciatica	
M54.6	Pain in the thoracic spine	M46.41-
M46.47	Discitis, unspecified, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region	M54.40-
M54.42	Lumbago with sciatica	
M54.81	Occipital neuralgia	M48.00-
M48.08	Spinal stenosis	M96.1	Postlaminectomy syndrome, NEC	
M54.89	Other dorsalgia	M48.34	Traumatic spondylopathy, thoracic region	 	 	
M54.9	Dorsalgia, unspecified	M50.10-
M50.13	Cervical disc disorder with radiculopathy	 	 	
R51	Headache	M50.80-
M50.83	Other cervical disc disorders	 	 	
 	 	M50.90-
M50.93	Cervical disc disorder, unspecified	 	 	
 	 	M51.14-
M51.17	Intervertebral disc disorders with radiculopathy, thoracic region, thoracolumbar region, lumbar region, lumbosacral region	 	 	
 	 	M51.84-
M51.87	Other thoracic, thoracolumbar and lumbosacral intervertebral disc disorders	 	 	
 	 	M53.0	Cervicocranial syndrome	 	 	
 	 	M53.1	Cervicobrachial syndrome	 	 	
 	 	M53.2X1-
M53.2X9	Spinal instabilities	 	 	
 	 	M53.3	Sacrococcygeal disorders NEC	 	 	
 	 	M53.80	Other specified dorsopathies, site unspecified	 	 	
 	 	M53.84-
M53.88	Other specified dorsopathies, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal region	 	 	
 	 	M53.9	Dorsopathy, unspecified	 	 	
 	 	M54.10-
M54.18	Radiculopathy	 	 	
 	 	M60.80	Other myositis, unspecified site	 	 	
 	 	M60.811,
M60.812	Other myositis, shoulder, right, left	 	 	
 	 	M60.819	Other myositis, unspecified shoulder	 	 	
 	 	M60.821,
M60.822	Other myositis, upper arm, right, left	 	 	
 	 	M60.829	Other myositis, unspecified upper arm	 	 	
 	 	M60.831,
M60.832	Other myositis, forearm, right, left	 	 	
 	 	M60.839	Other myositis, unspecified forearm	 	 	
 	 	M60.841,
M60.842	Other myositis, hand, right, left	 	 	
 	 	M60.849	Other myositis, unspecified hand	 	 	
 	 	M60.851,
M60.852	Other myositis, thigh, right, left	 	 	
 	 	M60.859	Other myositis, unspecified thigh	 	 	
 	 	M60.861,
M60.862	Other myositis, lower leg, right, left	 	 	
 	 	M60.869	Other myositis, unspecified lower leg	 	 	
 	 	M60.871,
M60.872	Other myositis, ankle and foot, right, left	 	 	
 	 	M60.879	Other myositis, unspecified ankle and foot	 	 	
 	 	M60.88,
M60.89	Other myositis, other site, multiple sites	 	 	
 	 	M60.9	Myositis, unspecified	 	 	
 	 	M62.830	Muscle spasm of back	 	 	
 	 	M72.9	Fibroblastic disorder, unspecified	 	 	
 	 	M79.1	Myalgia	 	 	
 	 	M79.2	Neuralgia and neuritis, unspecified	 	 	
 	 	M79.7	Fibromyalgia	 	 	
 	 	M99.20-
M99.23	Subluxation stenosis of neural canal, head region, cervical region, thoracic region, lumbar region	 	 	
 	 	M99.30-
M99.33	Osseous stenosis of neural canal, head region, cervical region, thoracic region, lumbar region	 	 	
 	 	M99.40-
M99.43	Connective tissue stenosis of neural canal, head region, cervical region, thoracic region, lumbar region	 	 	
 	 	M99.50-
M99.53	Intervertebral disc stenosis of neural canal, head region, cervical region, thoracic region, lumbar region	 	 	
 	 	M99.60-
M99.63	Osseous and subluxation stenosis of intervertebral foramina, head region, cervical region, thoracic region, lumbar region	 	 	
 	 	M99.70-
M99.73	Connective tissue and disc stenosis of intervertebral foramina, head region, cervical region, thoracic region, lumbar region	 	 	
 	 	Q76.2	Congenital spondylolisthesis	 	 	
 	 	S13.4XXA,
S13.4XXD	Sprain of ligaments of cervical spine, initial encounter, subsequent encounter	 	 	
 	 	S13.8XXA,
S13.8XXD	Sprain of joints and ligaments of other parts of neck, initial encounter, subsequent encounter	 	 	
 	 	S16.1XXA,
S16.1XXD	Strain of muscle, fascia and tendon at neck level, initial encounter, subsequent encounter	 	 	
 	 	S23.3XXA,
S23.3XXD	Sprain of ligaments of thoracic spine, initial encounter, subsequent encounter	 	 	
 	 	S23.8XXA,
S23.8XXD	Sprain of other specified parts of thorax, initial encounter, subsequent encounter	 	 	
 	 	S33.5XXA,
S33.5XXD	Sprain of ligaments of lumbar spine, initial encounter, subsequent encounter	 	 	
 	 	S33.6XXA,
S33.6XXD	Sprain of sacroiliac joint, initial encounter, subsequent encounter	 	 	
* NEC means not elsewhere classified.
	      b.    	 The neuromusculoskeletal conditions listed in the table in paragraph “a” generally require short-, moderate-, or long-term CMT. A diagnosis or combination of diagnoses within Category I generally requires short-term CMT of 12 per 12-month period. A diagnosis or combination of diagnoses within Category II generally requires moderate-term CMT of 18 per 12-month period. A diagnosis or combination of diagnoses within Category III generally requires long-term CMT of 24 per 12-month period. For diagnostic combinations between categories, 28 CMTs are generally required per 12-month period. If the CMT utilization guidelines are exceeded, documentation supporting the medical necessity of additional CMT must be submitted with the Medicaid claim form or the claim will be denied for failure to provide information.
	      c.    	 CMT is not a covered benefit when:
	       (1)  	 The maximum therapeutic benefit has been achieved for a given condition.
	       (2)  	 There is not a reasonable expectation that the continuation of CMT would result in improvement of the patient’s condition.
	       (3)  	 The CMT seeks to prevent disease, promote health and prolong and enhance the quality of life.
	   78.8(3) Documenting X-ray. An X-ray must document the primary regions of subluxation being treated by CMT.
	      a.    	 The documenting X-ray must be taken at a time reasonably proximate to the initiation of CMT. An X-ray is considered to be reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of CMT. X-rays need not be repeated unless there is a new condition and no payment shall be made for subsequent X-rays, absent a new condition, consistent with paragraph “c” of this subrule. No X-ray is required for pregnant women and for children aged 18 and under.
	      b.    	 The X-ray films shall be labeled with the patient’s name and date the X-rays were taken and shall be marked right or left. The X-ray shall be made available to the department or its duly authorized representative when requested. A written and dated X-ray report, including interpretation and diagnosis, shall be present in the patient’s clinical record.
	      c.    	 Chiropractors shall be reimbursed for documenting X-rays at the physician fee schedule rate. Payable X-rays shall be limited to those Current Procedural Terminology (CPT) procedure codes that are appropriate to determine the presence of a subluxation of the spine. Criteria used to determine payable X-ray CPT codes may include, but are not limited to, the X-ray CPT codes for which major commercial payors reimburse chiropractors. The Iowa Medicaid enterprise shall publish in the Chiropractic Services Provider Manual the current list of payable X-ray CPT codes. Consistent with CPT, chiropractors may bill the professional, technical, or professional and technical components for X-rays, as appropriate. Payment for documenting X-rays shall be further limited to one per condition, consistent with the provisions of paragraph “a” of this subrule. A claim for a documenting X-ray related to the onset of a new condition is only payable if the X-ray is reasonably proximate to the initiation of CMT for the new condition, as defined in paragraph “a” of this subrule. A chiropractor is also authorized to order a documenting X-ray whether or not the chiropractor owns or possesses X-ray equipment in the chiropractor’s office. Any X-rays so ordered shall be payable to the X-ray provider, consistent with the provisions in this paragraph.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 2164C, IAB 9/30/15, effective 10/1/15]