Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-15 - Chiropractic Services
Subsection 144-101-II-15.07 - POLICIES AND PROCEDURES
Universal Citation: 10 ME Code Rules ยง 144-101-II-15.07
Current through 2024-38, September 18, 2024
15.07-1 Diagnosis
A. 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:
1. Mensuration;
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.
15.07-2 Treatment Exceeding Twelve (12) Visits per Calendar Year
A. 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.
15.07-3 Member Records
The 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.
Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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