907 KAR 3:125. Chiropractic services
and reimbursement.
RELATES TO: KRS 312.015, 312.017, 42
C.F.R. 440.230, 441 Subpart B
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 205.560, Pub.L. 109-171
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet
for Health and Family Services, Department for Medicaid Services, has
responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes
the cabinet, by administrative regulation, to comply with any requirement that
may be imposed or opportunity presented by federal law for the provision of
medical assistance to Kentucky’s indigent citizenry. This administrative
regulation establishes the provisions relating to chiropractic services for
which payment shall be made by the Medicaid Program on behalf of both the
categorically needy and the medically needy.
Section 1. Definitions. (1)
"Chiropractic service" means the diagnosis and the therapeutic
adjustment or manipulation of the subluxations of the articulations of the
human spine and its adjacent tissues performed by, and within the scope of
licensure of, a licensed chiropractor in accordance with KRS 312.015 and
312.017.
(2) "Chiropractor" is defined
in KRS 312.015(3).
(3) "Current procedural terminology
code" or "CPT code" means the code used for reporting procedures
and services performed by medical practitioners and published annually by the
American Medical Association in Current Procedural Terminology.
(4) "Department" means the
Department for Medicaid Services or its designee.
(5) "Medically necessary" or
"medical necessity" means that a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.
(6) "Usual and customary
charge" means the uniform amount that a medical provider charges to a
private-pay patient or third-party payor in the majority of cases for a
specific medical procedure or service.
Section 2. Covered Services. (1) A
covered chiropractic service shall include the following:
(a) An evaluation and management service;
(b) Chiropractic manipulative treatment;
(c) Diagnostic X-rays;
(d) Application of a hot or cold pack to
one (1) or more areas;
(e) Application of mechanical traction to
one (1) or more areas;
(f) Application of electrical stimulation
to one (1) or more areas; or
(g) Application of ultrasound to one (1)
or more areas.
(2) A chiropractic service shall be
covered to the extent that the same service is covered by the department for a
physician and with the same reimbursement limits.
(3) A chiropractic service shall be
reported using:
(a) An evaluation and management CPT
code;
(b) A chiropractic manipulative treatment
CPT code;
(c) A diagnostic X-ray CPT code; or
(d) Physical modality application CPT
codes for the following:
1. Application of a hot or cold pack to
one (1) or more areas;
2. Application of mechanical traction to
one (1) or more areas;
3. Application of electrical stimulation
to one (1) or more areas; or
4. Application of ultrasound to one (1)
or more areas.
(4) Coverage of chiropractic services
shall:
(a) Be based on medical necessity;
(b) Be limited to twenty-six (26) visits
per recipient per twelve (12) month period.
Section 3. Reimbursement for Covered
Services. (1) A charge for a chiropractic service submitted to the department
for payment shall not exceed the usual and customary charge to a private-pay
patient or third-party payor for an identical procedure or service.
(2) For reimbursement of a covered
service, a chiropractor shall be paid the lessor of the chiropractor’s usual
and customary actual billed charge or an amount determined in accordance with
the Medicaid Physician Fee Schedule established in 907 KAR 3:010.
Section 4. Conditions for Provider
Participation. A participating chiropractor shall:
(1) Be licensed as a chiropractor in Kentucky or in the geographic location in which chiropractic services are provided;
(2) Have an active Medicare provider
number; and
(3) Meet the requirements for provider
participation in the Kentucky Medicaid Program in accordance with 907 KAR
1:671, 907 KAR 1:672, and 907 KAR 1:673.
Section 5. Appeal Rights. (1) An appeal
of a negative action taken by the department regarding a Medicaid recipient
shall be in accordance with 907 KAR 1:563.
(2) An appeal of a negative action taken
by the department regarding Medicaid eligibility of an individual shall be in
accordance with 907 KAR 1:560.
(3) An appeal of a negative action taken
by the department regarding a Medicaid provider shall be in accordance with 907
KAR 1:671. (27 Ky.R. 2015; Am. 2487; eff. 3-6-2001; 33 Ky.R. 624; 1409; 1588;
eff. 1-5-07.)