907 KAR 3:125. Chiropractic services and reimbursement

Link to law: http://www.lrc.ky.gov/kar/907/003/125.htm
Published: 2015

      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.)
Read Entire Law on www.lrc.ky.gov