Subsection 144-101-II-15.07 - POLICIES AND PROCEDURES15.07-1DiagnosisA. If CMS approves, the chiropractor may use the evaluation and management codes 99201-99215 for the purposes of examining and diagnosing a spinal condition. Treatment of spinal conditions must be billed using the spinal manipulation treatment codes 98940-98942 listed in Chapter III of this policy.B. The Chiropractor's recent examination of the member must include, but is not limited to the examinations listed below: 2. Biomechanical Evaluation;3. Neurological Evaluation;4. Kinesiological Evaluation; and 5. Orthopedic Evaluation.C. For the purposes of this requirement, recent shall mean within thirty (30) days prior to the initiation of treatment.D. MaineCare members who also qualify for Medicare shall meet the diagnostic requirements of the Medicare program.15.07-2Treatment Exceeding Twelve (12) Visits per Calendar YearA. For all eligible MaineCare members requiring Covered Services herein beyond twelve (12) visits per calendar year, a primary care provider or prescribing provider (MD, DO, PA, or APRN), who is licensed and acting within the scope of his or her license, must provide a referral describing the medical necessity of Covered Services beyond twelve (12) visits per calendar year.B. The Chiropractor must submit documentation to support the medical necessity of treatment exceeding twelve (12) visits per calendar year. This should include full clinical data, x-rays, progress notes, or other documentation to support the medical necessity for additional Covered Services.C. In addition to the requirements of subpart (A), for all eligible members age twenty-one (21) and over, Prior Authorization is required before the delivery of any additional Covered Services beyond twelve(12) visits per calendar year.D. X-ray services do not require Prior Authorization.15.07-3Member RecordsThe Department requires a specific record for each member that includes but is not limited to:
A. The member's name, address, birthdate, and MaineCare I.D. number.B. The member's social and medical history, and diagnoses.C. A personalized plan of service including (at a minimum):1. Type of chiropractic services needed;2. How the services can best be delivered, and the provider who will deliver the services;3. Frequency of services and expected duration of services;4. Long and short range goals;5. Plans for coordination with other health service providers for the delivery of services and the transfer of x-rays, if needed; and 6. Documentation of x-ray findings or results of the examinations described in 15.007-1 (Diagnosis) supporting the medical necessity of the services to be delivered.D. An adult member's Rehabilitation Potential.E. Progress notes must be maintained and include:1. The name of the provider, a full description of the condition, and the date of each service provided;2. Any progress toward the achievement of established long and short-range goals;3. The signature of the servicing provider for each service; and 4. A full account of any unusual condition or unexpected event, including the date when it was observed. The Department requires entries to be made for each service billed. When the services delivered vary from the plan of care, entries in the member's record must justify the changes.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-15, subsec. 144-101-II-15.07