Chapter 19 Chiropractic Services - South Country …SCHA Provider Manual Chapter 19 Chiropractic...

SCHA Provider Manual Chapter 19 Chiropractic Services January 2018

Chapter 19

Chiropractic Services

Chiropractic: Services are medically necessary therapies that employ manipulation and specific adjustment of body structures, such as the spinal column, provided by a licensed doctor of chiropractic. Eligible Providers Providers eligible for South Country Health Alliance (SCHA) reimbursement for chiropractic services must be licensed, credentialed and contracted. Out-of-network care may be eligible for reimbursement, pending medical necessity and availability of care; please contact our Provider Services line at 1-800-995-4543 for more information. Covered Services

• Manual manipulation of the spine for treatment of subluxation (incomplete or partial dislocation) that is directly associated with a presenting complaint that is determined to be medically necessary by the clinical treatment guidelines. Chiropractors performing manual manipulation of the spine may be reimbursed for such services when performed with handheld devices such as the “Activator”, but no additional payment shall be made when such a device is used.

• X-rays that meet treatment guidelines to support a diagnosis of subluxation. • Acupuncture may be covered for pain and other specific conditions. (For

additional information, please see SCHA Provider Manual Chapter 6: Medical Management or visit: https://mnscha.org/wp-content/uploads/Chapter6.pdf)

• Evaluation and Management Services

Benefit Limitations SCHA will monitor the utilization trend beyond 6 visits in a 30-day period, and 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 SCHA or members. Chiropractic utilization beyond the 6 visits per 30-days and 24 visits per calendar year thresholds will be reviewed for medical appropriateness based on evidenced based standards of care and medical necessity criteria. One evaluation per calendar year to determine medical necessity or progress. 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.

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• Use the most appropriate chiropractic, E/M, or X-ray code for the service provided as outlined in this chapter.

Reimbursement for X-rays is limited to radiological examinations needed to support a subluxation diagnosis; i.e.: full spine; the cervical, thoracic, lumbar, and lumbosacral areas of the spine; the pelvis; and the sacroiliac joints. Authorization is not required for any combination of procedure codes 98940, 98941 and 98942. Documenting subluxation The diagnosis of subluxation may be demonstrated using x-ray or physical examination. By radiological examination If submitting x-rays (or radiologic report) as documentation of the diagnosis, the x-ray must be no older than 12 months prior to the start of treatment. By physical examination Use evaluation of musculoskeletal or nervous system to identify the following:

• Pain or tenderness evaluated in terms of location, quality and intensity • Asymmetry or misalignment identified on a sectional or segmental level • Range of motion abnormality (changes in active, passive and accessory joint) • Tissue, tone changes in the characteristics of contiguous, or associated soft

tissues, including skin, fascia, muscle, and ligament Two of the above criteria are required to demonstrate subluxation based on physical examination. One of these criteria must be:

• Asymmetry or misalignment, or • Range of motion abnormality

This documentation must be provided to SCHA if, upon monitoring the utilization trend, we find the need to do a review to determine medical need of the services provided. Non-covered Services The following list of non-covered services is not all-inclusive. Other services may be provided but are not covered.

• Maintenance care, preventive care, or wellness care • Nutritional supplements, vitamins, or nutritional counseling • Acupressure • Treatment of a neurogenic or congenital condition that is not related to a

diagnosis of subluxation • Laboratory services • X-Rays, other than those determined to be necessary to support a diagnosis of

subluxation • Medical equipment or supplies that are either supplied or prescribed by the

chiropractor • Exercise, counseling, or activities of daily living counseling • Physiotherapy modalities including, but not limited to the following:


- Ultrasound - Diathermy - Electrical muscle stimulation - Interferential current - Application of hot packs and cold packs - Massage - Manual muscle stimulation - Russian stimulation

Member Enrollment Verification SCHA members have a member identification card and should present that card at the time of service. Providers should verify current member eligibility prior to providing services as the member’s eligibility may have expired after the card was issued. For additional information please go to Chapter 13 of SCHA provider manual, Member Enrollment. Billing Procedure Please go to Chapter 4 of the Provider Manual, Provider Billing, for detailed information on submitting billing for SCHA members. Chiropractic claims should be submitted electronically in 837P Professional format. Providers refer to your contract with SCHA for additional information on covered services, documentation, fee schedule and clinical guidelines. Submit the most applicable ICD diagnosis codes when billing for subluxation on claims. Overview of SCHA Guidelines for Chiropractic Treatment Chiropractic treatment is an important component of the SCHA care model, but has very specific guidelines associated with it. These guidelines allow for chiropractic services to be provided without the need for routine prior authorization. When the guidelines are not observed and care is provided outside of these parameters, the services are subject to utilization review which can reduce or exclude services from reimbursement. Some key areas to become familiar with from your SCHA Clinical Treatment Guidelines for Chiropractic Services are included here. Health Record Documentation Standards – A health care provider must maintain a record of all treatment provided to a patient. If the records are handwritten they must be legible to others, not just the writer. They must express coherent ideas and describe the services provided to a unique patient. Documentation methods that require a key to interpret are discouraged. Initial Chiropractic Visit Document the following for the initial chiropractic visit:

• Date of initial treatment • History: include the following:


o Symptoms causing patient to seek treatment o Family history if relevant o Past health history (general health, prior illness, injuries, or

hospitalizations, medications, surgical history) o Mechanism of trauma o Quality and character of symptoms or problem o Onset, duration intensity, frequency, location and radiation of symptoms o Aggravating or relieving factors o Prior interventions, treatment, medications, secondary complaints o Symptoms causing patient to seek treatment

• Evaluation of musculoskeletal or nervous system through physical examination • Diagnosis: subluxation must be the primary diagnosis • Treatment plan which includes:

o Recommended level of care o Specific treatment goals o Objective measures to evaluate effectiveness of treatment

Subsequent Visits Documentation required for subsequent visits include:

• History o Review of chief compliant o Changes since last visit o System review, if relevant

• Physical exam o Exam of area of spine involved in diagnosis o Assessment of change in patient condition since last visit o Evaluation of treatment effectiveness o Documentation of treatment provided on day of visit

30-day treatment plan – SCHA treatment frequency standards are based on a 30-day treatment period that begins at the initial visit. Note that this time period is not a calendar month, but a distinct 30-day period that begins with the initial visit. A typical treatment plan for an adult allows for up to 6 visits in a 30-day period. If a patient presents on the 15th of the June for example, that 30-day period runs through the 14th of July. Ongoing Care past the initial treatment period – Care that continues beyond the initial 30-day treatment period must be supported by daily patient notes and clinical exam findings that demonstrate progressive improvement. When improvement plateaus, or if the condition worsens, continued care beyond the initial 30-day treatment period is either considered to be maintenance care or contraindicated to medical necessity. In either case the care is not covered. Decreased Intensity and Frequency of Care – Treatment guidelines describe effective care reflected by decreasing intensity of care in the level of adjustment as well as the frequency of care over the course of treatment. This results in an overall ratio of


1:1 for 98940 to 98941 adjustments network wide. A treatment course that remains high in frequency and intensity will be subject to review as it does not reflect a progressive improvement in the patient’s condition. X-Rays – While x-rays remain a valuable tool for diagnosing patient conditions, today’s improved clinical exam techniques and practitioner diagnostic skills in this area allow most chiropractic patients to be safely treated without exposing them to the risk and expense of x-rays. X-rays are indicated in cases where trauma has occurred or the chiropractor has reason to suspect some other pathology is present, such as a tumor, fracture, infection, congenital anomaly or the patient has not responded as expected to an initial course of chiropractic care. Treatment of Children/Infants – SCHA has adopted conservative treatment guidelines for this group of patients. Chiropractic care within the initial 30-day treatment period should be limited to 4 visits for infants and toddlers (Birth through 4) and 5 visits for children 5 through 17. The SCHA benefit covers spinal related conditions only. Treatment of childhood conditions such as colic, bed wetting, and ear infection must have clear subluxation levels documented. The treatment outcome expectation for these patients is for them to respond within the initial treatment period. If they do not, continued care is not indicated as SCHA prefers these conditions be closely monitored by the member’s primary care physician. Upon subsequent examination by the primary care physician, if continued chiropractic treatment is indicated a referral from the PCP will be necessary. Daily notes required with claims – Daily treatment notes must be submitted in the following cases:

1. Treatment of a patient age birth through age 4 2. When a treatment code 98942 is used 3. When X-Rays have been taken

Case Management and Referral –SCHA members may access complex case management if needed. Complex case managers can be a valuable resource to chiropractic providers when there is a need to bring other health care disciplines together to develop a multi disciplinary plan of care or assistance with the referral of a challenging patient. If you need assistance with a referral to Complex Case Management, contact SCHA. Quality Monitoring Standards – The SCHA Quality Assurance Committee has established the following provider performance measures that your own clinic’s performance will be measured against. These are based on actual network utilization data and community standards of care. Of particular emphasis to all new providers is that up-coding of the manual manipulation code is prohibited. Compensation for adjusting 3 or 4 areas of the spine (98941) requires that the patient presents with symptoms documented in those same areas.


SCHA is accountable to assure the appropriate treatment and accurate billing of services provided to patients; therefore, these are monitored very closely. Billing for a higher level of treatment than the patient’s condition or complaint warrants, or up-coding, is fraudulent and SCHA is responsible to identify and report it when encountered. SCHA’s Quality Assurance Council has established a Quality measure standard for the expected ratio of patient adjustments of 50% 98940 and 50% 98941 from practitioners in the SCHA chiropractic network. Providers need to become familiar with the Quality Monitoring Standards as your clinic’s own performance will be measured against these as you provide services to SCHA members.


Clinical Treatment Guidelines for Chiropractic Services

Table of Contents

Part Title Page

A. Clinical Requirements and Care Model 8

B. Definition of Terms 11

C. Clinical Documentation Standards 13

D. Medical Imaging Guidelines 17

E. Cervical Pain Treatment Guidelines 20

F. Thoracic Back Pain Treatment Guidelines 25

G. Low Back Pain Treatment Guidelines 30


Part A: Clinical Requirements and Care Model

Date Approved: December 1, 2017 Effective Date: January 1, 2018 Review Dates:

South Country Health Alliance (SCHA) supports a community standard based clinical approach to providing effective chiropractic patient care. Our practitioners utilize patient treatment methods that conform to all applicable state, local, and federal laws, blending proven postural techniques, exercises, education and effective therapies with chiropractic mobilization and manipulation. SCHA reimburses Practitioners for approved medically necessary services only, as defined in this document and referenced in the SCHA Provider Participation Agreement. SCHA will not reimburse a Practitioner for non-covered or excluded services.

Chiropractic treatment emphasizes:

• The need for patients to understand the cause of their symptoms to actively participate in the treatment of their condition

• Treatment that incorporates realistic lifestyle changes, including home exercise and workplace activities patients can follow

A. Clinical Requirements:

1. SCHA clinical treatment guidelines are intended to assist the clinician in decision making based on the expectations of outcome for the typical case. They are not intended to be prescriptive toward a specific course or frequency of treatment for any specific case. They are a network benchmark by which determination of medically necessary care will be based and as such, should be taken under advisement in the provision of services to SCHA Members.

2. Practitioners agree to provide SCHA eligible Members (enrollees and subscribers or dependents) with chiropractic treatment for covered neuromusculoskeletal (NMS) conditions. In doing so, practitioners agree to abide by SCHA clinical and administrative policies and procedures as outlined in the Clinical Treatment Guidelines and the SCHA Provider Manual.


3. The treating practitioner uses his/her best clinical judgment regarding the propriety of any specific procedure considering the circumstances presented by the patient. The clinical course of care provided is subject to retrospective clinical review of the appropriateness of that care.

4. Acute disorders and uncomplicated cases typically respond within 14 days with 4 to 6 treatments. SCHA guidelines do not support daily treatment of patients and a plan to do so must be authorized in advance by SCHA. The patient medical record will clearly document progressive improvement within this timeframe as described in the SCHA documentation standards. Practitioners agree to refer Members, if requested or indicated, to other health care professionals for evaluation and treatment of conditions that are not neuromusculoskeletal (NMS) as well for as NMS conditions that have not responded to chiropractic care within the above timeframe.

5. Chronic disorders and complicated cases will typically respond within 16 weeks or will need re-assessment or referral. Specific length of treatment will be discussed between the provider and SCHA clinical management personnel. Practitioners agree to refer Members if requested or indicated, to other health care professionals for evaluation and treatment of conditions that are not neuromusculoskeletal (NMS) as well for as NMS conditions that have not responded to chiropractic care within the above timeframe.

6. Maximum care for patients within the first 30 days of the initial treatment is typically 6 visits for adults, 4 visits for patients age birth through 4, and 5 visits for patients age 5 through 17.

7. Practitioners will utilize differential diagnosis to rule out conditions that are non-mechanical or non-NMS. These conditions, when identified, require medical referral or concurrent care.

B. The clinical care model incorporates assessment, examination, diagnosis and treatment into a clinical treatment model as follows: Step 1: Assessment entails a thorough patient interview and review of the

patient's medical records to understand the patient's:

• current history • past history • family history • previous treatment and imaging studies • laboratory results


Step 2: Examination is completed utilizing appropriate vital sign testing, repetitive spinal movements, orthopedic, neurological and chiropractic evaluation to: identify the origin of the patient's symptoms; and formulate a treatment plan to relieve the patient’s reported symptoms and observed signs.

Step 3: Diagnosis is a conclusion arrived at after the assessment and examination determine if the patient is amenable to chiropractic care and if the patient should be referred to another health care provider.

Step 4: Treatment of the patient consists of both passive and active care:

First, an in-office treatment plan is developed. The patient is educated as to the cause of his/her symptoms and the behavioral factors contributing to the symptoms. A treatment plan is formulated for the patient including active and passive care. In-office treatment consists of spinal stretching/exercise, deep tissue work, appropriate therapies, spinal and extremity mobilization and manipulation.

Secondly, a self-care plan is developed for each patient, including:

1. patient follow through with the home exercise program that the patient demonstrated learning during the course of the in-office treatment phase and

2. the ongoing self-monitoring of postural correctness while sitting, standing and walking, along with the adoption of proper bending and lifting techniques.


Part B: Definition of Terms


1. Scope. The terms used in the SCHA treatment guidelines will have the following meanings given them.

2. Active treatment. "Active treatment" means treatment which requires active patient participation in a therapeutic program to increase flexibility, strength, endurance, or awareness of proper body mechanics.

3. Chronic pain syndrome. "Chronic pain syndrome" means any set of verbal or nonverbal behaviors that:

a. involves the complaint of enduring pain;

b. differs from the patient's pre-injury or onset of symptoms behavior;

c. has not responded to previous appropriate treatment;

d. is not consistent with a known organic syndrome which has remained untreated; and

e. interferes with physical, psychological, social, or vocational functioning.

4. Condition. A patient's "condition" means the symptoms, physical signs, clinical findings and functional status that characterize the complaint, illness, or injury presented by the patient.

5. Emergency treatment. "Emergency treatment" means treatment that is:

a. required for the immediate diagnosis and treatment of a medical condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death; or…

b. immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may


not represent an actual emergency but that is necessary to determine whether an emergency exists.

6. Etiology. "Etiology" means the anatomic alteration, physiologic dysfunction, or other biological or psychological abnormality which is considered a cause of the patient's condition.

7. Functional status. "Functional status" means the ability of an individual to engage in activities of daily living and other social, recreational, and vocational activities.

8. Initial non-surgical management or treatment. "Initial non-surgical management or treatment" is initial treatment provided after an injury that includes passive treatment, active treatment, injections, and durable medical equipment.

9. Medical imaging procedures. A "medical imaging procedure" is a technique, process or technology used to create a visual image of the body or its function. Medical imaging includes, but is not limited to: X-rays, tomography, angiography, venography, myelography, computed tomography (CT) scanning, magnetic resonance imaging (MRI) scanning, ultrasound imaging, nuclear isotope imaging, PET scanning, and thermography.

10. Medically necessary treatment. "Medically necessary treatment" means those health services that are reasonable and necessary for the diagnosis and cure or significant relief of a condition consistent with any applicable treatment guideline. The treatment must be reasonable and necessary for the diagnosis or cure and significant relief of a condition consistent with the current accepted standards of practice within the scope of the provider's license.

11. Neurologic deficit. "Neurologic deficit" means a loss of function secondary to involvement of the central or peripheral nervous system. This may include, but is not limited to, motor loss; spasticity; loss of reflex; radicular or anatomic sensory loss; loss of bowel, bladder, or erectile function; impairment of special senses, including vision, hearing, taste, or smell; or deficits in cognitive or memory function.

a. "Static neurologic deficit" means any neurologic deficit that has remained the same by history or noted by repeated examination since onset.

b. "Progressive neurologic deficit" means any neurologic deficit that has become worse by history or noted by repeated examination since onset.

12. Passive treatment. “Passive treatment” modalities include thermal treatment; traction; acupuncture; electrical muscle stimulation; braces; manual and mechanical therapy; massage; and adjustments.


Part C: Clinical Documentation Standards


1. Documentation Standards. A health care provider must maintain an appropriate record of all examinations and treatment provided to a patient. The minimum standard within a state is defined by statute and by the rules of the State Board of Chiropractic Examiners. Patient records must be legible, express coherent ideas and describe the services provided to a unique patient. Documentation methods that require a key to interpret are discouraged. The standards of the SCHA Network incorporate the following elements:

A. A description of past conditions and trauma, past treatment received, current treatment received from other health care providers, and a description of the patient’s current condition including onset and description of trauma if trauma occurred.

B. Examinations performed to determine a preliminary diagnosis based on indicated diagnostic tests, with an indication of all findings of each test performed.

C. A diagnosis supported by documented subjective and objective findings or clearly qualified as an opinion.

D. A treatment plan that describes the procedures and treatment used for the conditions identified, including approximate frequency of care.

E. Daily notes documenting current subjective complaints as described by the patient, any change in objective findings if noted during that visit, a listing of all procedures provided during that visit and information that is exchanged and will affect that patient’s treatment.

F. A description by the chiropractor or written by the patient each time an incident occurs that results in an aggravation of the patient’s condition or a new developing condition.


G. Results of reexaminations that are performed to evaluate significant changes in a patient’s condition, including tests that were positive or deviated from results used to indicate normal findings.

H. When symbols or abbreviations are used, a key that explains their meanings must accompany each file when requested in writing by the patient or a third part.

I. Documentation that family history has been evaluated.

SCHA has adopted the PARTS concept as a minimal acceptable level of documentation for supporting medically necessary care as follows:

PAIN

• Subjective: Presentation, History, Location and Quality • Objective: Observation, Palpation, Percussion, Provocative maneuvers

ASYMMETRY

• Observation of postural deviations • Palpatory malposition • Radiographic malposition • Presence of neurological deficits

RANGE OF MOTION

• Active and passive range of motion abnormalities • Segmental motion palpation • Stress or motion radiography

TONE, TEXTURE and TEMPERATURE

• Observation of body contours • Soft tissue palpation characteristics • Instrumentation techniques • Neurological examination

SPECIAL TEST and CONSIDERATIONS

• Orthopedic tests and prevocational maneuvers • Symptoms (particularly visceral) that may be related to particular areas of

neurological dysfunction

2. Medically Necessary Treatment. All treatment must be medically necessary. Medically Necessary Treatment is defined as those health services that are reasonable and necessary for the diagnosis and cure or significant relief of a condition consistent with any applicable treatment guideline. The medical necessity


definition extends to include the prevention of progressive deterioration of a condition. The treatment must be reasonable and necessary for the diagnosis or cure, significant relief of or prevention of progressive deterioration of a condition with the current accepted standards of practice within the scope of the provider's license. Treatments rendered should have a cumulative effect on improving the patient’s condition. The health care provider must evaluate the medical necessity of all treatment on an ongoing basis. SCHA’s Treatment Guidelines do not require or permit more frequent examinations than would typically be required for the condition being treated, but do require ongoing evaluation of the patient that is medically necessary, consistent with accepted medical practice.

3. Criteria for Progressive Improvement. The health care provider must evaluate at each visit whether the therapeutic treatment is effective according to the criteria for progressive improvement as listed below:

a. the patient's subjective complaints are progressively improved, as evidenced in the medical record by documentation of decreased distribution, frequency or intensity of symptoms;

b. the objective clinical findings are progressively improving, as evidenced in the medical record by documentation of resolution or objectively measured improvement in the patient’s condition; and

c. the patient's functional status, at home, at work, and/or at leisure activities, is progressively improving, as evidenced by documentation in the medical record.

If there is not progressive improvement in at least two of these areas, the treatment should be either discontinued or significantly modified. In such cases the provider should reconsider the diagnosis and treatment plan. The evaluation of the effectiveness of the treatment modality remains the ultimate responsibility of the treating health care provider who prescribed the treatment. If further treatment is not indicated, the provider should assist the patient with a referral to another appropriate health care provider for further evaluation.

4. Treatment Plan Expectations. The health care provider should establish an appropriate treatment plan. The provider should educate and inform the patient regarding all aspects of the treatment being provided as well as the probable cause of the patient’s condition. The provider should also discuss with the patient what they can do to augment the treatment being provided such as home exercise or restrictions of exacerbating activities. The provider should clearly explain the expectations for improvement in the patient’s condition as a result of the plan of treatment.


5. Chemical dependency and domestic abuse. The health care provider shall maintain diligence to detect chemical dependency and/or domestic abuse issues involving the patient. The health care provider shall counsel the patient to seek appropriate evaluation and treatment of the chemical dependency. Issues concerning suspected domestic abuse may be reported to authorities in accordance with applicable state and/or federal statutes.


Part D: Medical Imaging Guidelines


1. General principles. All medical imaging must comply with the items below. Except for emergency evaluation of significant trauma, a health care provider must document in the medical record an appropriate history and physical examination, along with a review of any existing medical records and laboratory or imaging studies regarding the patient's condition, before ordering any imaging study.

a. Appropriate Imaging. A health care provider should order the most appropriate imaging study for diagnosing the suspected etiology of a patient's condition. No concurrent or additional imaging studies should be ordered until the results of the first study are known and reviewed by the treating health care provider. If the first imaging study is negative, no additional imaging is indicated except for repeat and alternative imaging allowed under item b (6).

X-Rays are indicated in the following cases:

1. Where trauma has occurred to rule out a dislocation or fracture. The trauma must have occurred within four weeks prior to the visit. If the need for treatment is the result of bending, lifting, exercise, sleeping wrong or waking up with pain, this is typically not considered to be trauma but rather a strain/sprain postural injury. Such complaints do not by themselves meet the criteria of significant trauma.

2. Unexplained or unintended weight loss or the reasonable suspicion of some other sinister pathology including but not limited to tumor, pathological fracture, infection, bone weakening disorder, or congenital anomaly.

3. In cases where the patient has not responded to a reasonable course of conservative therapy within the first 30 days.


4. In cases where there are significant clinical findings suggesting the presence of underlying pathology.

5. In cases where examination findings are confirmed by pertinent orthopedic and neurological exams that warrant X-rays to rule out pathology prior to treatment, such as to differentiate between a disc herniation and other lesions that could occupy the same space.

6. In cases with a history of spinal surgery or other surgery in the area that is to be treated

7. In cases where the symptoms are unremitting and have become progressively more severe and/or are of a severity to cause the patient to awake at night.

b. Cases where imaging is not appropriate

1. Imaging solely to rule out a diagnosis not seriously being considered as the etiology of the patient's condition is not indicated.

2. X-rays for a simple sprain/strain or confirmation of a diagnosis of subluxation are not indicated. Spinal pain alone is not an indicator of a clinical need for spinal X-Rays.

3. Routine imaging. Imaging on a routine basis is not indicated.

4. Imaging to assess biomechanical changes from previous imaging

5. Complete regional, cervical, thoracic, and lumbar X-Rays are rarely indicated and should be reserved for cases of significant trauma.

6. Repeat imaging. Repeat imaging, of the same views of the same area of the body with the same imaging modality is not indicated except to diagnose a suspected fracture, dislocation, or to monitor scoliosis in an adolescent patient.

(1) Repeat imaging is not appropriate solely to determine the efficacy of chiropractic treatment.

(2) Persistence of a patient’s subjective complaint or failure of the condition to respond to treatment are not indications for repeat imaging, but rather indications that a referral to an appropriate health care practitioner should be made to evaluate the patient’s


condition and further course of treatment.

7. SCHA does not deny coverage of imaging based solely because imaging does not meet evidence based standards.


Part E: Cervical Pain Guidelines


Section 1. Diagnostic procedures for treatment of cervical pain. A health care provider shall determine the nature of the condition before initiating treatment.

a. An appropriate history and physical examination must be performed and documented. Based on the history and physical examination the health care provider must assign the patient at each visit to the appropriate clinical category according to items (1) to (4) listed below. The diagnosis must be documented in the medical record on initial visit. For the purposes of items (2) and (3), "radicular pain" means pain radiating distal to the shoulder. This Part does not apply to fractures of the cervical spine or cervical pain due to an infectious, immunologic, metabolic, endocrine, visceral, or neoplastic disease process.

(1) Regional neck pain includes referred pain to the shoulder and upper back. Regional neck pain includes the diagnoses of cervical strain, sprain, myofascial syndrome, musculoligamentous condition, radicular sensations to the head and throat, headache, concussion, soft tissue conditions and other diagnoses for pain believed to originate in the osseous structures, discs, ligaments, muscles, or other soft tissues of the cervical spine and which affects the cervical region, with or without referral to the upper back or shoulder

(2) Radicular pain, with or without regional neck pain, with no static neurologic deficit. This includes the diagnoses of brachialgia; cervical radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with radiculopathy, radiculitis, or neuritis; spinal stenosis with radiculopathy, radiculitis, or neuritis; and other diagnoses for pain in the arm distal to the shoulder believed to originate with irritation of the spinal cord or a nerve root in the cervical spine. In these cases, neurologic findings on history and examination are either absent or do not show progressive deterioration.

(3) Radicular pain, with or without regional neck pain, with progressive neurologic deficit, which includes the same diagnoses as item (2); however, in these cases there is a history of progressive deterioration in


the neurologic symptoms and physical findings, including worsening sensory loss, increasing muscle weakness, and progressive reflex changes.

(4) Cervical compressive myelopathy, with or without radicular pain, is a condition characterized by weakness and spasticity in one or both arms and/or legs and associated with any of the following: exaggerated reflexes, an extensor plantar response, bowel or bladder dysfunction, sensory ataxia, or bilateral sensory changes.

b. Laboratory tests are not indicated in the evaluation of a patient with regional neck pain, or radicular pain. If the treating chiropractor suspects infection, metabolic-endocrine disorders, tumorous conditions, systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis a referral should be made to an appropriate health care professional.

c. Medical imaging evaluation of the cervical spine must be based on the findings of the history and physical examination and cannot be ordered prior to the health care provider's clinical evaluation of the patient. Medical imaging should not be performed as a routine procedure and must comply with SCHA’s guidelines for imaging. The health care provider must document the appropriate indications for any medical imaging studies obtained.

Section 2. General treatment parameters for neck pain.

a. All medical care for neck pain appropriately assigned to a clinical category in section 1, item a, is determined by the diagnosis and clinical category in section 1, item a, to which the patient has been assigned. General parameters for treatment modalities are set forth in sections 3 to 6. The health care provider must, at each visit, reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing, and opinions and information obtained from consultations with other health care providers. When the clinical category is changed, the treatment plan must be appropriately modified to reflect the new clinical category. However, a change of clinical category does not in itself allow the health care provider to continue a therapy or treatment modality past the recommended duration specified in sections 3 to 6, or to repeat a therapy or treatment provided for the same patient’s condition or complaint.

b. A course of treatment is divided into three phases.

(1) Patients with neck problems, except patients with radicular pain with progressive neurological deficit, or myelopathy under section 1, item a, sections (3) and (4), should be given initial chiropractic care which may include both active and passive treatment modalities.


(2) Patients with radicular pain with progressive neurological deficit or myelopathy may require surgical intervention. If the chiropractor’s findings suggest surgery may be necessary, a referral to an appropriate health care provider should be considered.

(3) For those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be indicated. A chronic management program must be approved by the SCHA chiropractic director.

c. A treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice.

Section 3. Passive treatment modalities.

a. The general guideline for frequency of visits involving passive treatment of the patient in a clinical setting shall be as follows:

Adults age 18 years and over

6 visits decreasing in frequency of visits and/or intensity of services over the first 30 days of treatment. Consistent and progressive improvement in the patient’s condition must be evident from the daily patient treatment records.

Children ages 5 through 17 years of age.

5 visits within the first 30 days of treatment. Consistent and progressive improvement in the patient’s condition must be evident from the daily patient treatment records.

Children ages birth through 4 years of age.

1-4 visits within the first 30 days of treatment. Consistent and progressive improvement in the patient’s condition must be evident from the daily patient treatment records.

• All care provided beyond the first 30 days must be supported by documentation of progressive improvement of the patient’s condition.

• Coverage for services is governed by the individual health plan fee schedule and the patient’s chiropractic benefit as described in the patient’s insurance certificate of coverage.


• The health care provider must document in the medical record a plan to encourage the patient's independence and decreased reliance on continued passive treatment;

b. Chiropractic adjustment or manipulation of joints:

(1) time for treatment response, three to five treatments;

(2) maximum treatment frequency:

• up to three visits in the first week of treatment. • Patients 18 years and over: 6 visits over the first 30 days. • Patients 5 Years through 17 years of age. 5 visits over the first 30

days • Patients ages Birth through 4 years of age. 4 visits over the first 30

days.

c. Thermal treatment includes all superficial and deep heating and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluid therapy. Deep thermal modalities include diathermy, ultrasound, cool laser light therapy and microwave.

(1) Treatment given in a clinical setting in conjunction with chiropractic manipulation: time for treatment response, two to four treatments.

(2) Home use of thermal modalities may be prescribed at any time during the course of treatment. Home use may only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, and cold soaks which can be applied by the patient without health care provider assistance. Home use of thermal modalities does not require any special training or monitoring, other than that usually provided by the health care provider during an office visit.

d. Electrical muscle stimulation includes galvanic stimulation, TENS, interferential, and micro current techniques.

(1) Treatment given in a clinical setting:

(a) time for treatment response, two to four treatments

e. Mechanical traction:


(a) time for treatment response, two to four treatments

Home use of a mechanical traction device may be prescribed as follow-up to use of traction in a clinical setting if it has proven to be effective treatment and is expected to continue to be effective treatment. Initial use of a mechanical traction


device must be in a supervised setting in order to ensure proper patient education.

f. Manual therapy includes soft tissue and joint mobilization, therapeutic massage and manual traction:

(1) time for treatment response, two to four treatments

g. Bed rest. Prolonged restriction of activity and immobilization is detrimental to a patient's recovery. Bed rest is not recommended.

Section 4. Active treatment modalities. The treating chiropractor should provide education for the patient that includes training on posture, biomechanics and relaxation. Appropriate exercise instruction should be provided to actively engage the patient in the treatment program and make them less reliant on passive care provided in the clinic setting.

Section 5. Chronic management. Every chronic pain patient eventually reaches a plateau where the cumulative effect of ongoing care is not positive, showing no evidence of progressive improvement. Chronic management of back pain is typically considered to be maintenance care. Insurance will not pay for care of this kind. The patient may be offered an out of pocket maintenance program or discharged/referred to a PT or their primary care doctor for further evaluation and care.

Section 6. Evaluation of treatment by health care provider. The health care provider must evaluate at each visit whether the treatment is medically necessary, and must evaluate whether initial chiropractic treatment is effective according to items a to c that follow. The health care provider must continually evaluate whether the passive or active treatment modality is resulting in progressive improvement as specified in the following items a through c:

a. the patient’s subjective complaints of pain or disability are progressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms;

b. the objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs; and

c. the patient's functional status, especially is progressively improving, as evidenced by documentation in the medical record of less restrictive limitations on activity.

If there is not progressive improvement in at least two of these areas (a to c), the treatment must be discontinued or significantly modified, or a referral made to another appropriate health care provider. The evaluation of the effectiveness of the treatment modality is the ultimate responsibility of the treating health care provider.


Part F: Thoracic Back Pain Guidelines


Section 1. Diagnostic procedures for treatment of thoracic back injury. A health care provider shall determine the nature of the condition before initiating treatment.

a. An appropriate history and physical examination must be performed and documented. Based on the history and physical examination the health care provider must assign the patient at each visit to the consistency appropriate clinical category according to items (1) to (3) listed below. The diagnosis must be documented in the medical record. For the purposes of items (2) and (3), "radicular pain" means pain radiating in a dermatomal distribution. This Part does not apply to fractures of the thoracic spine or thoracic back pain due to an infectious, immunologic, metabolic, endocrine, visceral, or neoplastic disease process.

(1) Regional thoracic back pain includes the diagnoses of thoracic strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, and any other diagnosis for pain believed to originate in the osseous structures, discs, ligaments, muscles, or other soft tissues of the thoracic spine and which affects the thoracic region

(2) Radicular pain, with or without regional thoracic back pain, includes the diagnoses of thoracic radiculopathy, or radiculitis; displacement or herniation of intervertebral disc with radiculopathy, or radiculitis; spinal stenosis with radiculopathy, or radiculitis; and any other diagnoses for pain believed to originate with irritation of a nerve root in the thoracic spine.

(3) Thoracic compressive myelopathy, with or without radicular pain, is a condition characterized by weakness and spasticity in one or both legs and associated with any of the following: exaggerated reflexes, an extensor plantar response (+Babinski sign), bowel or bladder dysfunction, sensory ataxia or bilateral sensory changes.

b. Laboratory tests are not initially indicated in the evaluation of a patient with regional thoracic back pain, or radicular pain. If the treating provider suspects infection, metabolic-endocrine disorders, tumorous conditions, or systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis,


a referral to an appropriate health care provider should be made for co-management.

c. Medical imaging evaluation of the thoracic spine must be based on the findings of the history and physical examination and cannot be ordered prior to the health care provider's clinical evaluation of the patient. Medical imaging may not be performed as a routine procedure. The health care provider must document the appropriate indications for any medical imaging studies obtained.

d. Personality or psychological evaluations should be considered for patients who continue to have problems despite appropriate care. The treating provider should arrange for referral to an appropriate health care provider.

Section 2. General treatment parameters for thoracic back pain.

a. All chiropractic care for thoracic back pain, appropriately assigned to a clinical category in Section 1, item a, is determined by the clinical category to which the patient has been assigned. General parameters for treatment modalities are set forth in sections 3 to 6. The health care provider must, at each visit, reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing, and opinions and information obtained from consultations with other health care providers. When the clinical category is changed, the treatment plan must be appropriately modified to reflect the new clinical category. However, a change of clinical category does not in itself allow the health care provider to continue a therapy or treatment modality past the maximum duration specified in Sections 3 to 6, or to repeat a therapy or treatment previously provided for the same condition or complaint.


(1) All patients with thoracic back problems, except patients with myelopathy under Section 1, a, item (3), must be given initial non-surgical management which may include active and passive treatment modalities. These modalities and parameters are described in Sections 3, 4, 5, and 6.

(2) Patients with radicular pain with progressive neurological deficit or myelopathy may require surgical intervention. If the chiropractor’s findings suggest surgery may be necessary, a referral to an appropriate health care provider should be considered.

(a) Patients with myelopathy may require immediate surgical intervention.

(b) Any patient who has had surgery may require postoperative therapy with active and passive treatment modalities. This therapy


may be in addition to any received during the period of initial non-surgical care.

(3) For those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be indicated.

c. Consultations. A treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice.




6 visits, decreasing in frequency of visits and/or intensity of services over the first 30 days of treatment. Consistent and progressive improvement in the patient’s condition must be evident from the daily patient treatment records.





• All care provided beyond the first 30 days must be supported by documentation of progressive improvement in the patient’s condition.

• Coverage for services is governed by the individual patient’s health plan’s certificate of coverage and the SCHA fee schedule.


(1) time for treatment response, two to four treatments;

(2) maximum treatment frequency:

• up to three visits in the first week of treatment. • Patients 18 years and over: 6 visits over the first 30 days.


• Patients 5 Years through 17 years of age. 5 visits over the first 30 days

• Patients ages Birth through 4 years of age. 4 visits over the first 30 days

c. Thermal treatment includes all superficial and deep heating modalities and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluid therapy. Deep thermal modalities include diathermy, ultrasound, cool laser light therapy and microwave.

(1) Treatment given in a clinical setting in conjunction with chiropractic manipulation:

(a) time for treatment response, two to four treatments;


d. Electrical muscle stimulation includes galvanic stimulation, TENS, interferential and micro current techniques.






(2) Home use of a mechanical traction device may be prescribed as follow-up to use of traction in a clinical setting if it has proven to be effective treatment and is expected to continue to be effective treatment. Initial use of a mechanical traction device must be in a supervised setting to ensure proper patient education.

f. Manual therapy includes soft tissue and joint mobilization, therapeutic massage and manual traction:

(1) time for treatment response, two to four treatments;

g. Bed rest. Prolonged restriction of activity and immobilizations are detrimental to a patient's recovery. Bed rest is not recommended.


Section 4. Active treatment modalities. The treating chiropractor should provide education for the patient that includes training on posture, biomechanics and relaxation. Appropriate exercise instruction should be provided to actively engage the patient in the treatment program and make them less reliant on passive care provided in the clinic setting.


Section 6. Evaluation of treatment by health care provider. The health care provider must evaluate at each visit whether the treatment is medically necessary, and must evaluate whether initial chiropractic treatment is effective according to the following items from a to c. The health care provider must continually evaluate whether the passive or active treatment modality is resulting in progressive improvement as specified in the following items a to c:

a. The patient's subjective complaints of pain or disability are progressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms;

b. The objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs of injury; and

c. The patient's functional status, is progressively improving, as evidenced by documentation in the medical record, of less restrictive limitations on activity.

If there is not progressive improvement in at least two items of items a to c, the modality must be discontinued or significantly modified, or a referral made to an appropriate health care provider. The evaluation of the effectiveness of the treatment modality is the ultimate responsibility of the treating health care provider.


Part G: Low Back Pain Guidelines


Section 1. Diagnostic procedures for treatment of low back pain.

A health care provider shall determine the nature of the condition before initiating treatment.

a. An appropriate history and physical examination must be performed and documented. Based on the history and physical examination the health care provider must assign the patient at each visit to the appropriate clinical category according to items (1) to (3) listed below. The diagnosis must be documented in the medical record. For the purposes of items (2) and (3), "radicular pain" means pain radiating from the lumbar spine proximal and/or distal to the knee, or pain conforming to a dermatomal distribution and possibly accompanied by anatomically congruent motor weakness or reflex changes. This Part does not apply to fractures of the lumbar spine, or back pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process.

(1) Regional low back pain, includes referred pain into the buttocks region unless it conforms to an L2, L3, or L4 dermatomal distribution and is accompanied by anatomically congruent motor weakness or reflex changes. Regional low back pain includes the diagnoses of lumbar, lumbosacral, or sacroiliac: strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, spondylosis, and other diagnoses for pain believed to originate in the osseous structures, discs, ligaments, muscles, or other soft tissues of the lumbar spine or sacroiliac joints and which affects the lumbosacral region, with or without referral to the buttocks region.

(2) Radicular pain, with or without regional low back pain, with static or no neurologic deficit. This includes the diagnoses of sciatica; lumbar or lumbosacral radiculopathy, radiculitis or neuritis; displacement or herniation of intervertebral disc with myelopathy, radiculopathy, radiculitis or neuritis; spinal stenosis with myelopathy, radiculopathy, radiculitis or neuritis; and any other diagnoses for pain in the buttocks region believed


to originate with irritation of a nerve root in the lumbar spine. In these cases, neurologic findings on history and physical examination are either absent or do not show progressive deterioration.

(3) Radicular pain, with or without regional low back pain, with progressive neurologic deficit. This includes the same diagnoses as item (2); however, this category applies when there is a history of progressive deterioration in the neurologic symptoms and physical findings which include worsening sensory loss, increasing muscle weakness, or progressive reflex changes.

b. Laboratory tests are not initially indicated in the evaluation of a patient with regional low back pain, or radicular pain. If the treating provider suspects infection, metabolic-endocrine disorders, tumorous conditions, or systemic musculoskeletal disorders, a referral to an appropriate health care provider should be made for co-management.

c. Medical imaging evaluation of the lumbar spine, lumbosacral spine or pelvis must be based on the findings of the history and physical examination and cannot be ordered before the health care provider's clinical evaluation of the patient. Medical imaging may not be performed as a routine procedure. The health care provider must document the appropriate indications for any medical imaging studies obtained.

d. Psychological evaluation should be considered for patients who continue to have problems despite appropriate care. The treating provider should arrange for referral to an appropriate health care provider.

Section 2. General treatment parameters for low back pain.

a. All medical care for low back pain, appropriately assigned to a clinical category in Section 1, item a, is determined by the clinical category to which the patient has been assigned. General parameters for treatment modalities are set forth in Sections 3 to 6. The health care provider must, at each visit, reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing, and opinions and information obtained from consultations with other health care providers. When the clinical category is changed, the treatment plan must be appropriately modified to reflect the new clinical category. However, a change of clinical category does not in itself allow the health care provider to continue a therapy or treatment modality past the recommended duration specified in sections 3 to 6, or to repeat a therapy or treatment previously provided for the same patient’s condition or complaint.


(1) First, all patients with low back problems, except patients with progressive neurologic deficit under Section 1, a, item (3), must be given


initial non-surgical management which may include active treatment modalities and passive treatment modalities. These modalities and parameters are described in Section 3.

(a) Patients with radicular pain with progressive neurological deficit or myelopathy may require surgical intervention. If the chiropractor’s findings suggest surgery may be necessary, a referral to an appropriate health care provider should be considered.

(b) Any patient who has had surgery may require postoperative therapy in a clinical setting with active and passive treatment modalities.

(2) For those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be indicated.

c. Regarding referral for consultation, a treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice.




6 visits, decreasing in frequency of visits and/or intensity of services over the first 30 days of treatment. Consistent and progressive improvement in the patient’s condition must be evident from the daily patient treatment records.





• All care provided beyond the first 30 days must be supported by documentation of progressive improvement in the patient’s condition.


• Coverage for services is governed by the individual health plan fee schedule and the patient's chiropractic benefit.

• The health care provider must document in the medical record a plan to encourage the patient’s independence and decreased reliance on continued passive treatment;

• Management of the patient's condition must include active treatment modalities during this period;


(1) Time for treatment response, three to five treatments;

(2) Maximum treatment frequency:

• up to three visits in the first week of treatment • Patients 18 years and over: 6 visits over the first 30 days • Patients 5 Years through 17 years of age: 6 visits over the first 30

days • Patients ages Birth through 4 years of age: 4 visits over the first 30

days

c. Thermal treatment includes all superficial and deep heating and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluid therapy. Deep thermal modalities include diathermy, ultrasound, cool laser light therapy and microwave.

(1) Treatment given in a clinical setting in conjunction with chiropractic manipulation:

(a) Time for treatment response, two to four treatments.


d. Electrical muscle stimulation includes galvanic stimulation, TENS, interferential, and micro-current techniques.


(a) Time for treatment response, two to four treatments;




(a) Time for treatment response, two to four treatments;

(2) Home use of a mechanical traction device may be prescribed as follow-up to use of traction in a clinical setting if it has proven to be effective treatment and is expected to continue to be effective treatment. Initial use of a mechanical traction device must be in a supervised setting to ensure proper patient education.

f. Manual therapy includes soft tissue and joint mobilization, therapeutic massage, and manual traction:

(1) Time for treatment response, two to four treatments;

g. Bed rest. Prolonged restriction of activity and immobilization are detrimental to a patient's recovery. Bed rest is not recommended.

Section 4. Active treatment modalities. The treating chiropractor should provide education for the patient that includes training on posture, biomechanics, and relaxation. Appropriate exercise instruction should be provided to actively engage the patient in the treatment program and make them less reliant on passive care provided in the clinic setting.


Section 6. Evaluation of treatment by health care provider. The health care provider must evaluate at each visit whether the treatment is medically necessary, and must evaluate whether initial chiropractic treatment is effective according to items a to c that follow. The health care provider must continually evaluate whether the passive or active treatment modality is resulting in progressive improvement as specified in the following items a to d:

a. the patient’s subjective complaints of pain or disability are progressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms;

b. the objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs; and

c. the patient's functional status is progressively improving, as evidenced by documentation in the medical record of less restrictive limitations on activity.


d. there has been an exacerbation or extenuating circumstances as evidenced by documentation in the medical record.

If there is not progressive improvement in at least two of these areas (a to d), the modality must be discontinued or significantly modified, or a referral made to another appropriate health care provider. The evaluation of the effectiveness of the treatment modality is the ultimate responsibility of the treating health care provider.

Chapter 19 Chiropractic Services - South Country …SCHA Provider Manual Chapter 19 Chiropractic...

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