UR-Chiro Form Revised

April 2016

WSI recently revised the UR-Chiro form and providers should use the revised form effective immediately.

Changes to the new form include the following:

  • General wording changes
  • Requested treatment and modality procedures now require indication of the specific CPT code(s). Below is an excerpt of the new UR-Chiro form that displays revised requested information in a mock example.

  • The number of modalities section should match the number of CPT codes listed for modalities. For example, if a provider checks “1” modality per visit, the provider should only list one CPT modality code, e.g. 97014
  • Treatment codes include manipulative treatment codes 98940-98943
  • Modality codes include the following:
    • Supervised (untimed) CPT codes 97010-97028
    • Constant Attendance (timed) CPT codes 97032-97039
    • Therapeutic Procedures (timed) CPT codes 97110-97546
  • A new question has been incorporated to inquire if the patient is receiving physical or occupational therapy as indicated in the below excerpt.

Complete the UR-Chiro form in its entirety, as WSI will return incomplete forms back to the provider. 

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