Coverage Criteria

Coverage Criteria A. A chiropractor must use the appropriate procedure code for manual manipulation of the spine to correct subluxation. Medicaid coverage will be provided for one (1) procedure code that encompasses the entire treatment for any given day. B. Necessity of treatment must be documented by use of the appropriate diagnosis code to report all of the following: 1. Treatment area as denoted by the appropriate primary diagnosis code. 2. Symptoms associated with subluxation as denoted by the appropriate second diagnosis code. 3. Complicating factors as denoted by the appropriate third diagnosis code. C. An x-ray is required to demonstrate that a subluxation exists unless the patient is: 1. Pregnant, 2. Suspects pregnancy which has not yet been confirmed, or 3. A child age twelve (12) years or less. D. The date of the x-ray or the exception(s) must be properly documented in the medical record including the: 1. Date of the x-ray which must be within twelve (12) months of the date of service. 2. Expected date of delivery if the patient is pregnant. 3. Date of last menstrual period if pregnancy is suspected but not confirmed. 4. Child’s date of birth when the child is twelve (12) years of age or less. The x-ray is at the discretion of the chiropractor. E. Medicaid applies the appropriate procedure codes for chiropractic services and x-ray procedures toward the seven hundred dollars ($700) per fiscal year (July 1 - June 30) per beneficiary.