Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
312.015,
312.017,
42 C.F.R.
440.230, 441 Subpart B
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.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.560,
Pub.L.
109-171
