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Based on provider feedback, WSI has outlined some points of clarification for providing chiropractic treatment to an injured worker. Below are some general reminders and additional information regarding the July 1, 2016 pilot program, which requires prior authorization for any chiropractic service extending beyond the initial office visit:

  • Definition of modality: WSI considers CPT® Physical Medicine and Rehabilitation codes 97010 through 97546 as modalities when conducted as chiropractic services.
  • Flexibility in treatment plan: There are two means for a chiropractor to attain flexibility in treatment choices for a given request:
    • Submit the CPT® codes considered for treatment on the Utilization Review Chiropractor Request (UR-Chiro) form. For example, if a chiropractor knows they may want to perform either ultrasound (97035) or electrical stimulation (97014) as part of a treatment plan, the request should include both of these codes as “97035 or 97014”.
    • Contact WSI to request a minor change or addition to an existing approval. For example, if a chiropractor receives approval for ultrasound (97035), but determines electrical stimulation (97014) is more medically appropriate, they may contact WSI and request a change to the approval.
  • Additional treatment beyond approved service: If WSI approves fewer visits than were requested, a chiropractor may pursue one of the following options:
    • Submit a new request upon completion of the approved visits. For example, if a chiropractor requests 12 visits and the number of visits approved is 6, they may submit a subsequent request for additional visits if warranted.
    • Submit an appeal by completing the UR-Chiro form with additional medical documentation to support the number of visits initially requested.
  • Extension of treatment plan timeframe: If a circumstance arises in which the number of visits cannot be completed within the approved timeframe, WSI may allow an extension of two weeks to complete the visits. A provider must contact WSI to initiate this request prior to the end date of the approved timeframe.
  • X-ray utilization: As outlined in the WSI Utilization Review Guide, an x-ray does not require prior authorization. WSI reimburses an x-ray when medical documentation supports the billed charge.
  • Importance of Orthopedic Chiropractic Consultant (OCC) recommendation letter: It is important to review the OCC recommendation letter thoroughly, as it may contain pertinent information not included in WSI’s UR decision letter. A chiropractor may contact OCC directly for questions regarding information provided in their recommendation letter.

If you have questions about this article, please send an email to wsipr@nd.gov.  To receive provider news, subscribe to our Email Updates list.

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