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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-8. Limited Practitioner Services |
5160-8-11. Spinal manipulation and related diagnostic imaging services
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(A) Scope. This rule sets forth provisions governing payment for professional, non-institutional spinal manipulation and related diagnostic imaging services. Provisions governing payment for such services performed in a federally qualified health center are set forth in Chapter 5160-28 of the Administrative Code.
(B) Providers.
(1) Rendering providers. The following eligible providers may render a service described in this rule:
(a) A chiropractor (an individual who holds a valid license as a chiropractor under Chapter 4734. of the Revised Code and works within the scope of practice defined by state law); or
(b) A mechanotherapist (an individual who holds a valid license as a mechanotherapist under Chapter 4731. of the Revised Code and works within the scope of practice defined by state law).
(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for submitting a claim for a covered service on behalf of a rendering provider:
(a) A chiropractor;
(b) A mechanotherapist;
(c) A professional medical group, which is described in rule 5160-1-17 of the Administrative Code;
(d) A hospital, rules for which are set forth in Chapter 5160-2 of the Administrative Code; or
(e) A fee-for-service clinic, rules for which are set forth in Chapter 5160-13 of the Administrative Code.
(C) Coverage.
(1) Payment for manual manipulation of the spine may be made only for the correction of a subluxation, the existence of which must be determined either by physical examination or by diagnostic imaging. If the determination is made by physical examination, the following criteria must be met:
(a) At least one of the following two conditions exists:
(i) Asymmetry or misalignment on a sectional or segmental level; or
(ii) Abnormality in the range of motion; and
(b) At least one of the following two symptoms is present:
(i) Significant pain or tenderness in the affected area; or
(ii) Changes in the tone or characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.
(2) Payment may be made only for the following services:
(a) Spinal manipulation.
(i) Chiropractic manipulative treatment (CMT); spinal, one to two regions.
(ii) Chiropractic manipulative treatment (CMT); spinal, three to four regions.
(iii) Chiropractic manipulative treatment (CMT); spinal, five regions.
(b) Diagnostic imaging to determine the existence of a subluxation.
(i) Spine, entire; survey study, anteroposterior and lateral.
(ii) Spine, cervical; anteroposterior and lateral.
(iii) Spine, cervical; anteroposterior and lateral; minimum of four views.
(iv) Spine, cervical; anteroposterior and lateral; complete, including oblique and flexion and/or extension studies.
(v) Spine, thoracic; anteroposterior and lateral views.
(vi) Spine, thoracic; complete, with oblique views; minimum of four views.
(vii) Spine, thoracolumbar; anteroposterior and lateral views.
(viii) Spine, lumbosacral; anteroposterior and lateral views.
(ix) Spine, lumbosacral; complete, with oblique views.
(x) Spine, lumbosacral; complete, including bending views.
(c) Acupuncture services in accordance with rule 5160-8-51 of the Administrative Code.
(D) Requirements, constraints, and limitations.
(1) The following coverage limits, which may be exceeded with prior authorization, are established for the indicated services:
(a) Spinal manipulation, one treatment per date of service;
(b) Diagnostic imaging of the entire spine to determine the existence of a subluxation, two sessions per benefit year;
(c) All other imaging, two sessions per six-month period; and
(d) Visits in an outpatient setting, thirty dates of service per benefit year for an individual younger than twenty-one years of age, fifteen dates of service per benefit year for an individual twenty-one years of age or older.
(2) Payment will not be made under this rule for any of the following services:
(a) A service that is not medically necessary, examples of which are shown in the following non-exhaustive list:
(i) A service unrelated to the treatment of a specific medical complaint;
(ii) Treatment of a disease, disorder, or condition that does not respond to spinal manipulation, such as multiple sclerosis, rheumatoid arthritis, muscular dystrophy, sinus problems, and pneumonia;
(iii) Preventive treatment;
(iv) Repeated treatment without an achievable and clearly defined goal;
(v) Repeated imaging or other diagnostic procedure for a chronic, permanent condition;
(vi) Treatment from which the maximum therapeutic benefit has already been achieved and the continuation of which cannot reasonably be expected to improve the condition or arrest deterioration within a reasonable and generally predictable period of time; and
(vii) A service performed more frequently than the standard generally accepted by peers;
(b) A service that is performed by someone other than a chiropractor or mechanotherapist who is an eligible provider; and
(c) A service that is performed by a chiropractor or mechanotherapist who is an eligible provider but that is neither chiropractic manipulation nor diagnostic imaging to determine the existence of a subluxation, illustrated by the following examples:
(i) Diagnostic studies;
(ii) Drugs;
(iii) Equipment used for manipulation;
(iv) Evaluation and management services;
(v) Injections;
(vi) Laboratory tests;
(vii) Maintenance therapy (therapy that is performed to treat a chronic, stable condition or to prevent deterioration);
(viii) Manual manipulation for purposes other than the treatment of subluxation;
(ix) Orthopedic devices;
(x) Physical therapy;
(xi) Supplies; and
(xii) Traction.