Section 5160-8-11 - Chiropractic services(A) Scope. This rule sets forth provisions governing payment for professional, non-institutional spinal manipulation and related diagnostic imaging services. (B) Providers. (1) Rendering providers. The following eligible providers may render a service described in this rule: (a) A chiropractor, defined in Chapter 4734. of the Revised Code.(b) A mechanotherapist, defined in Chapter 4731. of the Revised Code.(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: (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; (e) A nursing facility, rules for which are set forth in Chapter 5160-3 of the Administrative Code;(f) An ambulatory health care clinic, rules for which are set forth in Chapter 5160-13 of the Administrative Code; or(g) A federally qualified health center (FQHC), rules for which are set forth in Chapter 5160-28 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 is to be determined either by diagnostic imaging or by physical examination confirming that the following criteria are 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) Evaluation and management services. (i) Office or other outpatient visit for the evaluation and management of a new patient, involving either straightforward medical decision-making or a total time of from fifteen to twenty-nine minutes.(ii) Office or other outpatient visit for the evaluation and management of a new patient, involving either low-level medical decision-making or a total time of from thirty to forty-four minutes.(iii) Office or other outpatient visit for the evaluation and management of an established patient, for which the presence of a physician or other qualified healthcare professional may not be needed.(iv) Office or other outpatient visit for the evaluation and management of an established patient, involving either straightforward medical decision-making or a total time of from ten to nineteen minutes.(v) Office or other outpatient visit for the evaluation and management of an established patient, involving either low-level medical-decision making or a total time of from twenty to twenty-nine minutes.(3) For a covered chiropractic service rendered at an FQHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.(D) Constraints and limitations. (1) The following coverage limits 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; (d) Evaluation and management, four sessions per benefit year; and(e) 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 not chiropractic manipulation, diagnostic imaging to determine the existence of a subluxation, or evaluation and management, illustrated by the following examples: (iii) Equipment used for manipulation; (vi) Maintenance therapy (therapy that is performed to treat a chronic, stable condition or to prevent deterioration);(vii) Manual manipulation for purposes other than the treatment of subluxation;(viii) Orthopedic devices;Ohio Admin. Code 5160-8-11
Effective: 11/1/2022
Five Year Review (FYR) Dates: 5/1/2026
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 02/10/1986, 12/31/1986 (Emer.), 03/22/1997, 07/01/2002, 01/01/2004, 01/01/2008, 05/08/2016, 01/01/2018, 06/12/2020 (Emer.), 05/01/2021