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1. What chiropractic services are and are not covered by Iowa
Medicaid?
Answer: Coverage and payment by Iowa Medicaid is limited
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.” [See 441 IAC 78.8(1)] No other chiropractic services are
covered or payable, such as office visits, extra spinal manipulation,
treatment using other modalities (e.g. hot/cold packs,
electro-stimulation, use of mechanized treatment modalities,
acupuncture, orthopedic devices, etc.).
2. What are the limitations and indications of coverage for
chiropractic services under Iowa Medicaid?
Answer: As provided under 441 IAC 78.8(2), the subluxation must have
resulted in a neuromusculoskeletal condition for which chiropractic
manipulative therapy (CMT) is an appropriate treatment. These
neuromusculoskeletal conditions are described in the chiropractic
diagnostic categories listed under the Iowa Medicaid rules at 441
IAC 78.8(2)“a” and in the Chiropractic Services provider manual on
pages E-5 – E7. 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. As specified
under 441 IAC 78.8(2)“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; or (3)
The CMT seeks to prevent disease, promote health and prolong and
enhance the quality of life. CMT covered by Iowa Medicaid
corresponds to diagnostic categories, which specify treatment limits
by each such category. This is addressed under 441 IAC 78.8(2)“a”
and at pages E-5 - E-7 of the Chiropractic Services provider manual.
The number of chiropractic treatments available corresponds to three
diagnostic categories, based on the diagnoses indicated on the
claims submitted by the chiropractor. The specifications for each
diagnostic category are as follows:
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Category I may receive up to 12 chiropractic treatments per 12
month period
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Category II up to 18 treatments per 12 month period
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Category III up to 24 treatments per 12 month period
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Combinations across diagnostic categories may receive up to 28
treatments per 12-month period.
The 12-month period is a “rolling” period, where the claims payment
system looks 12 months back from the current date of service. So
going forward, the oldest visits drop off the count. For instance,
if a patient is seen today, the claims payment system will look back
12 months from today’s date of service. If that patient is seen 1
month from today, the claims system will look back 12 months from
that date, and so-on.
CMT beyond stated treatment limits is addressed under 441 IAC
78.8(2)“b” and provides that: “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.” Under this
rule, chiropractors may also request prior authorization for
treatments beyond treatment limits in advance of rendering services.
As such, there exists a vehicle through which chiropractors may
request approval for additional visits beyond stated treatment
limits without having to request an exception to policy.
3. What are the advantages and disadvantages of being an Iowa
Medicaid provider?
Answer: Only enrolled providers can receive payment by the Iowa
Medicaid program. Many chiropractors, especially in rural areas,
serve low-income patients. Many of these patients are (or could
become eligible to be) Iowa Medicaid recipients. A chiropractor’s
enrollment with Medicaid assures that s/he will be able to receive
payment for covered services from the Medicaid program. This is
arguably a far better option for assuring payment than not being
enrolled and having to seek payment directly from low-income
patients.
4. How does the “rolling” 12-month calendar work, relative to
tracking chiropractic services, relative to chiropractic treatment
limits?
Answer: See response to question 2, above.
5. Does Iowa Medicaid follow Medicare coverage policy?
Answer: Generally, Iowa Medicaid does follow Medicare coverage
policy for chiropractic services, relative to the types of
chiropractic services that are covered. However, there are some key
differences. As far as similarities, Iowa Medicaid coverage policy
under 441 IAC 78.8(249A) provides that: “Payment will be made for
the same chiropractic procedures payable under the Medicare
program.” This means that Iowa Medicaid will cover and provide
payment for the same limited services recognized by Medicare.
Specifically, this means that payment is limited 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.” [See 441
IAC 78.8(1)] No other chiropractic services are covered, such as
extra spinal manipulation, treatment using other modalities (e.g.
hot/cold packs, electro-stimulation, use of mechanized treatment
modalities, etc.). It is important to note that Iowa Medicaid does
NOT follow Medicare relative to policy regarding demonstration of
subluxation (i.e. use of the P.A.R.T. methodology). This is
addressed in greater detail, below.
6. Does Iowa Medicaid still require x-rays to demonstrate the area(s)
of subluxation?
Answer: Yes. Iowa Medicaid did not follow Medicare policy changes in
2000 that discontinued their x-ray requirement and replacing it with
use of the P.A.R.T. methodology to provide demonstration of areas of
subluxation. Instead, Iowa Medicaid opted to retain the x-ray
requirement. The rationale for this decision was based on the Iowa
Medicaid program’s belief that an x-ray was a more reliable way of
documenting subluxations than the P.A.R.T. methodology. In retaining
the x-ray requirement, however, chiropractic coverage policy was
amended to provide payment to chiropractors for selected x-ray
procedures. Previously, Iowa Medicaid did not provide payment to
chiropractors for x-rays for documentation of subluxations.
Chiropractic payment for x-rays was set at the then-current fee
schedule rate applicable to MDs and DOs. The x-ray procedures
selected were based upon input sought and received from the Iowa
Chiropractic Society.
7. Does Iowa Medicaid provide reimbursement to chiropractors for
x-rays to demonstrate the area(s) of subluxation?
Answer: Yes. As noted in question 7, above, Iowa Medicaid did not
follow Medicare’s movement to the P.A.R.T. methodology and retained
the x-ray requirement. As an accommodation to chiropractors, Iowa
Medicaid did change policy in 2000 to allow payment to chiropractors
for a limited range of X-rays typically used to demonstrate the
area(s) of subluxation. Iowa Medicaid chiropractic x-ray
coverage/payment policy is addressed under 441 IAC 78.8(3) and
provides in pertinent part that:
“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.” [See 441 IAC 78.8(3)“c”]
8. What can chiropractors do to assure that services they provide
are covered and paid, relative to Iowa Medicaid chiropractic
treatment limits?
Answer: As discussed under question 2, above, CMT treatment limits
apply. It is recognized that in some cases, Iowa Medicaid recipients
may seek the services of more than one chiropractor. This may occur
simultaneously or sequentially. In other words, a recipient may be
using two different chiropractors at once, or they may discontinue
care with one chiropractor and subsequently initiate care with a
different one. Regardless of how this might occur, the treatment
limits applicable to each Medicaid recipient (by virtue of their
chiropractic diagnostic category) are based on ALL chiropractic
services a recipient receives in any given 12 month period. In other
words, treatment limits are tied to the recipient, not the
chiropractor. Therefore, it is incumbent upon Iowa Medicaid enrolled
chiropractors to confirm to the best of their ability where a
current Iowa Medicaid patient is at relative to their treatment
limits. The chiropractor will know what diagnostic category the
patient falls into. However, the chiropractor may not readily know
where any given Medicaid patient is relative to the treatment
limits. Chiropractors may contact IME at
800/338-7909
or 515/725-1004
(Local).
The foregoing notwithstanding, it would also be advisable for
chiropractors to ask Medicaid patients if they have used any other
chiropractors within the last 12 months, or whether they are
currently using another chiropractor. Additionally, chiropractors
should notify Medicaid patients that these treatment limits apply
and that if the chiropractor receives a denial based on exceeding
treatment limits, the Medicaid patient will be responsible for
payment of that service as a “non-covered” service. This is
consistent with the policy regarding a Medicaid provider’s obligation to inform Medicaid
patients of their obligations for non-covered services. Chiropractors
may also include a statement on any forms used generally in their
practices regarding patient financial obligations. For Medicaid
patients, such a statement could read: “I understand that any
services beyond Iowa Medicaid allowable treatment limits will be
considered ‘non-covered’ by Iowa Medicaid and that I will be
responsible for payment of those services.”
9. How should Iowa Medicaid providers handle provision of services
not covered by the Iowa Medicaid program?
Answer: Relative to non-covered services, Iowa Medicaid rules
require that: “Recipients must be informed before the service is
provided that the recipient will be responsible for the bill if a
non-covered service is provided.” [See 441 IAC 79.9(4)] Enrolled
providers are responsible for informing recipients accordingly. Many
Medicaid providers have begun using a standard form to be completed
by all Medicaid recipients in their practices that specifies the
recipient’s acknowledgement of financial responsibility for any
services not covered by Iowa Medicaid. The only caveat here is that
any form or provider office policy relative to Medicaid recipients
may not be materially different from forms or office policy relative
to all other patients of the practice. [See 441 IAC 79.9(3)] This
recipient payment responsibility also corresponds to information
provided by DHS to Medicaid recipients upon becoming eligible for
Medicaid. Each Medicaid recipient receives a booklet entitled “Your
Guide To Medicaid” which specifies that recipients will be
responsible for payment of services not covered by Iowa Medicaid.
For additional questions please contact a member of the
ICS Medicaid Committee.
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