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Billing
Diagnosis Codes
PrimeWest Health requires prior authorization for acupuncture services after a member has received 20 units within a calendar year. The following codes are affected by this requirement:
| Acupuncture | |
| Procedure Code | Brief Description |
| 97810 | Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes, one-to-one contact with patient |
| 97811 | Without electrical stimulation, each additional 15 minutes, one-to-one contact with patient |
| 97813 | With electrical stimulation, initial 15 minutes of personal one-to-one contact with the patient |
| 97814 | With electrical stimulation, each additional 15 minutes of personal one-to-one contact with the patient, with re-insertion of needles(s) (List separately in addition to code for primary procedure) |
Items that fall within an acupuncturist scope of practice, such as breathing techniques, dietary guidelines, and exercise based on Oriental principles, are considered part of an acupuncturist’s visit and are not reimbursed separately.
| Chiropractic Services | |
| Procedure Code | Brief Description |
| 98940 | Chiropractic manipulative treatment (CMT); spinal, one to two regions |
| 98941 | Spinal, three to four regions |
| 98942 | Spinal, five regions |
Medical Assistance (Medicaid), Special Needs BasicCare (SNBC), Minnesota Senior Care Plus (MSC+), and MinnesotaCare Claims
Providers must choose all applicable subluxation ICD-10-CM code(s) to identify the area(s) of subluxation. This guideline affects CPT codes 98940, 98941, and 98942. Listing all applicable diagnoses will confirm the medical necessity for the treatment provided. For example, if 98942 (five regions) is submitted with only four subluxation codes, it would be denied with EX64 (DENY – PROCEDURE INCONSISTENT WITH DIAGNOSIS – DTR-1202).
Diagnosis Codes
Providers are required to indicate the most applicable ICD-10-CM diagnosis codes when billing chiropractic or acupuncture services.
| ICD-10 | Brief Description |
| M99.01 | Segmental and somatic dysfunction of cervical region |
| M99.02 | Segmental and somatic dysfunction of thoracic region |
| M99.03 | Segmental and somatic dysfunction of lumbar region |
| M99.04 | Segmental and somatic dysfunction of sacral region |
| M99.05 | Segmental and somatic dysfunction of pelvic region |
| M99.10 | Subluxation complex (vertebral) of head region |
| M99.11 | Subluxation complex (vertebral) of cervical region |
| M99.12 | Subluxation complex (vertebral) of thoracic region |
| M99.13 | Subluxation complex (vertebral) of lumbar region |
| M99.14 | Subluxation complex (vertebral) of sacral region |
| S13.100A | Subluxation of unspecified cervical vertebrae – initial encounter |
| S13.100D | Subluxation of unspecified cervical vertebrae – subsequent encounter |
| S13.101A | Dislocation of unspecified cervical vertebrae – initial encounter |
| S13.101D | Dislocation of unspecified cervical vertebrae – subsequent encounter |
| S13.110A | Subluxation of C0/C1 cervical vertebrae – initial encounter |
| S13.110D | Subluxation of C0/C1 cervical vertebrae – subsequent encounter |
| S13.111A | Dislocation of C0/C1 cervical vertebrae – initial encounter |
| S13.111D | Dislocation of C0/C1 cervical vertebrae – subsequent encounter |
| S13.120A | Subluxation of C1/C2 cervical vertebrae – initial encounter |
| S13.120D | Subluxation of C1/C2 cervical vertebrae – subsequent encounter |
| S13.121A | Dislocation of C1/C2 cervical vertebrae – initial encounter |
| S13.121D | Dislocation of C1/C2 cervical vertebrae – subsequent encounter |
| S13.130A | Subluxation of C2/C3 cervical vertebrae – initial encounter |
| S13.130D | Subluxation of C2/C3 cervical vertebrae – subsequent encounter |
| S13.131A | Dislocation of C2/C3 cervical vertebrae – initial encounter |
| S13.131D | Dislocation of C2/C3 cervical vertebrae – subsequent encounter |
| S13.140A | Subluxation of C3/C4 cervical vertebrae – initial encounter |
| S13.140D | Subluxation of C3/C4 cervical vertebrae – subsequent encounter |
| S13.141A | Dislocation of C3/C4 cervical vertebrae – initial encounter |
| S13.141D | Dislocation of C3/C4 cervical vertebrae – subsequent encounter |
| S13.150A | Subluxation of C4/C5 cervical vertebrae – initial encounter |
| S13.150D | Subluxation of C4/C5 cervical vertebrae – subsequent encounter |
| S13.151A | Dislocation of C4/C5 cervical vertebrae – initial encounter |
| S13.151D | Dislocation of C4/C5 cervical vertebrae – subsequent encounter |
| S13.160A | Subluxation of C5/C6 cervical vertebrae – initial encounter |
| S13.160D | Subluxation of C5/C6 cervical vertebrae – subsequent encounter |
| S13.161A | Dislocation of C5/C6 cervical vertebrae – initial encounter |
| S13.161D | Dislocation of C5/C6 cervical vertebrae – subsequent encounter |
| S13.170A | Subluxation of C6/C7 cervical vertebrae – initial encounter |
| S13.170D | Subluxation of C6/C7 cervical vertebrae – subsequent encounter |
| S13.171A | Dislocation of C6/C7 cervical vertebrae – initial encounter |
| S13.171D | Dislocation of C6/C7 cervical vertebrae – subsequent encounter |
| S13.180A | Subluxation of C7/T1 cervical vertebrae – initial encounter |
| S13.180D | Subluxation of C7/T1 cervical vertebrae – subsequent encounter |
| S13.181A | Dislocation of C7/T1 cervical vertebrae – initial encounter |
| S13.181D | Dislocation of C7/T1 cervical vertebrae – subsequent encounter |
| S13.20XA | Dislocation of unspecified parts of neck – initial encounter |
| S13.20XD | Dislocation of unspecified parts of neck – subsequent encounter |
| S13.29XA | Dislocation of other parts of neck – initial encounter |
| S13.29XD | Dislocation of other parts of neck – subsequent encounter |
| S23.100A | Subluxation of unspecified thoracic vertebrae – initial encounter |
| S23.100D | Subluxation of unspecified thoracic vertebrae – subsequent encounter |
| S23.101A | Dislocation of unspecified thoracic vertebrae – initial encounter |
| S23.101D | Dislocation of unspecified thoracic vertebrae – subsequent encounter |
| S23.110A | Subluxation of T1/T2 thoracic vertebrae – initial encounter |
| S23.110D | Subluxation of T1/T2 thoracic vertebrae – subsequent encounter |
| S23.111A | Dislocation of T1/T2 thoracic vertebrae – initial encounter |
| S23.111D | Dislocation of T1/T2 thoracic vertebrae – subsequent encounter |
| S23.120A | Subluxation of T2/T3 thoracic vertebrae – initial encounter |
| S23.120D | Subluxation of T2/T3 thoracic vertebrae – subsequent encounter |
| S23.121A | Dislocation of T2/T3 thoracic vertebrae – initial encounter |
| S23.121D | Dislocation of T2/T3 thoracic vertebrae – subsequent encounter |
| S23.122A | Subluxation of T3/T4 thoracic vertebrae – initial encounter |
| S23.122D | Subluxation of T3/T4 thoracic vertebrae – subsequent encounter |
| S23.123A | Dislocation of T3/T4 thoracic vertebrae – initial encounter |
| S23.123D | Dislocation of T3/T4 thoracic vertebrae – subsequent encounter |
| S23.130A | Subluxation of T4/T5 thoracic vertebrae – initial encounter |
| S23.130D | Subluxation of T4/T5 thoracic vertebrae – subsequent encounter |
| S23.131A | Dislocation of T4/T5 thoracic vertebrae – initial encounter |
| S23.131D | Dislocation of T4/T5 thoracic vertebrae – subsequent encounter |
| S23.132A | Subluxation of T5/T6 thoracic vertebrae – initial encounter |
| S23.132D | Subluxation of T5/T6 thoracic vertebrae – subsequent encounter |
| S23.133A | Dislocation of T5/T6 thoracic vertebrae – initial encounter |
| S23.133D | Dislocation of T5/T6 thoracic vertebrae – subsequent encounter |
| S23.140A | Subluxation of T6/T7 thoracic vertebrae – initial encounter |
| S23.140D | Subluxation of T6/T7 thoracic vertebrae – subsequent encounter |
| S23.141A | Dislocation of T6/T7 thoracic vertebrae – initial encounter |
| S23.141D | Dislocation of T6/T7 thoracic vertebrae – subsequent encounter |
| S23.142A | Subluxation of T7/T8 thoracic vertebrae – initial encounter |
| S23.142D | Subluxation of T7/T8 thoracic vertebrae – subsequent encounter |
| S23.143A | Dislocation of T7/T8 thoracic vertebrae – initial encounter |
| S23.143D | Dislocation of T7/T8 thoracic vertebrae – subsequent encounter |
| S23.150A | Subluxation of T8/T9 thoracic vertebrae – initial encounter |
| S23.150D | Subluxation of T8/T9 thoracic vertebrae – subsequent encounter |
| S23.151A | Dislocation of T8/T9 thoracic vertebrae – initial encounter |
| S23.151D | Dislocation of T8/T9 thoracic vertebrae – subsequent encounter |
| S23.152A | Subluxation of T9/T10 thoracic vertebrae – initial encounter |
| S23.152D | Subluxation of T9/T10 thoracic vertebrae – subsequent encounter |
| S23.153A | Dislocation of T9/T10 thoracic vertebrae – initial encounter |
| S23.153D | Dislocation of T9/T10 thoracic vertebrae – subsequent encounter |
| S23.160A | Subluxation of T10/T11 thoracic vertebrae – initial encounter |
| S23.160D | Subluxation of T10/T11 thoracic vertebrae – subsequent encounter |
| S23.161A | Dislocation of T10/T11 thoracic vertebrae – initial encounter |
| S23.161D | Dislocation of T10/T11 thoracic vertebrae – subsequent encounter |
| S23.162A | Subluxation of T11/T12 thoracic vertebrae – initial encounter |
| S23.162D | Subluxation of T11/T12 thoracic vertebrae – subsequent encounter |
| S23.163A | Dislocation of T11/T12 thoracic vertebrae – initial encounter |
| S23.163D | Dislocation of T11/T12 thoracic vertebrae – subsequent encounter |
| S23.170A | Subluxation of T12/L1 thoracic vertebrae – initial encounter |
| S23.170D | Subluxation of T12/L1 thoracic vertebrae – subsequent encounter |
| S23.171A | Dislocation of T12/L1 thoracic vertebrae – initial encounter |
| S23.171D | Dislocation of T12/L1 thoracic vertebrae – subsequent encounter |
| S23.20XA | Dislocation of unspecified parts of thorax – initial encounter |
| S23.20XD | Dislocation of unspecified parts of thorax – subsequent encounter |
| S23.29XA | Dislocation of other parts of thorax – initial encounter |
| S23.29XD | Dislocation of other parts of thorax – subsequent encounter |
| S33.100A | Subluxation of unspecified lumbar vertebrae – initial encounter |
| S33.100D | Subluxation of unspecified lumbar vertebrae – subsequent encounter |
| S33.101A | Dislocation of unspecified lumbar vertebrae – initial encounter |
| S33.101D | Dislocation of unspecified lumbar vertebrae – subsequent encounter |
| S33.110A | Subluxation of L1/L2 lumbar vertebrae – initial encounter |
| S33.110D | Subluxation of L1/L2 lumbar vertebrae – subsequent encounter |
| S33.111A | Dislocation of L1/L2 lumbar vertebrae – initial encounter |
| S33.111D | Dislocation of L1/L2 lumbar vertebrae – subsequent encounter |
| S33.120A | Subluxation of L2/L3 lumbar vertebrae – initial encounter |
| S33.120D | Subluxation of L2/L3 lumbar vertebrae – subsequent encounter |
| S33.121A | Dislocation of L2/L3 lumbar vertebrae – initial encounter |
| S33.121D | Dislocation of L2/L3 lumbar vertebrae – subsequent encounter |
| S33.130A | Subluxation of L3/L4 lumbar vertebrae – initial encounter |
| S33.130D | Subluxation of L3/L4 lumbar vertebrae – subsequent encounter |
| S33.131A | Dislocation of L3/L4 lumbar vertebrae – initial encounter |
| S33.131D | Dislocation of L3/L4 lumbar vertebrae – subsequent encounter |
| S33.140A | Subluxation of L4/L5 lumbar vertebrae – initial encounter |
| S33.140D | Subluxation of L4/L5 lumbar vertebrae – subsequent encounter |
| S33.141A | Dislocation of L4/L5 lumbar vertebrae – initial encounter |
| S33.141D | Dislocation of L4/L5 lumbar vertebrae – subsequent encounter |
| S33.2XXA | Dislocation of sacroiliac and sacrococcygeal joint – initial encounter |
| S33.2XXD | Dislocation of sacroiliac and sacrococcygeal joint – subsequent encounter |
PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) claims must first list the area of subluxation. See Local Coverage Article: Chiropractic Services – Medical Policy Article (A57889), effective January 1, 2020, for Medicare guidelines.
PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Claims
Providers must first submit the subluxation ICD-10-CM code(s) to identify the area(s) of subluxation as the primary diagnosis code(s). The subsequent diagnosis codes must describe the level of subluxation. Listing all applicable diagnosis codes will confirm the medical necessity for the treatment provided. For example, if 98942 (five regions) is submitted with only four subluxation codes, it would be denied with EX64 (DENY – PROCEDURE INCONSISTENT WITH DIAGNOSIS – DTR-1202).
Pain, asymmetry, range of motion, and tissue tone change (PART) date is required.
Documentation of Subluxation: A subluxation may be demonstrated by an X-ray or by physical examination to identify PART. The PART date is listed as: “PART MMDDYY subluxation levels complaint” (example: PART 062207 C2 T5 L3 NECK PAIN).
Diagnosis Codes
It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-10-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.
The primary diagnosis must be subluxation, and must indicate the level of the subluxation. The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.
Payment Limitations
- PrimeWest Health will monitor the utilization trend beyond 24 visits that occur in a calendar year. An office visit for manual manipulation of the spine is considered part of the service and cannot be billed separately to PrimeWest Health or members.
- An Evaluation and Management (E/M) service is allowed on the same date of service as a spinal manipulation only if the E/M service is significant and separately identifiable from the procedure that is performed. Use modifier 25 to indicate that the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-procedure care associated with the service performed.
- Note: Do not use modifier 25 if the documentation shows that the amount of work performed is consistent with that normally performed with the procedure.
- Use the most appropriate chiropractic, E/M, or X-ray code for the service provided as outlined in this chapter.
Payment for X-rays is limited to radiological examinations of the full spine; the cervical, thoracic, lumbar, and lumbosacral areas of the spine; the pelvis; and the sacroiliac joints.
PW_11-19_530
Updated_12/21/2021
