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 III - Allowances for Services › Section 144-101-III-15 - Chiropractic Services

Current through 2024-29, July 17, 2024
DEFINITIONS
CPT Codes
: Current
					 Procedural Terminology codes of medical procedures and services developed and
					 published by the American Medical Association. Procedure codes and modifiers
					 can be referenced on the American Medical Association's website at:
					 http://www.ama-assn.org and the Centers for Medicare and Medicaid Services'
					 website at: http://www.cms.hhs.gov.
Modifiers
: A modifier
					 is a two-character code added as a suffix to the procedure code. Use of a
					 modifier indicates that a service has been altered by some specific
					 circumstance, but there are no changes in its definition or code. The
					 Department uses standard industry wide modifiers as identified in the American
					 Medical Association's publication of Current Procedural Terminology and the
					 Healthcare Common Procedure Coding System.
Pricing
					 Modifiers
:Radiology services are comprised of two parts,
					 the professional component and the administrative and technical component. A
					 provider may be reimbursed for supplying the professional component, the
					 administrative and technical component, or both. When billing for the
					 Professional component or the Administrative and Technical component, each of
					 these radiology services must include an appropriate modifier in addition to
					 the procedure code for payment. When billing for Total Professional,
					 Administrative and Technical radiology services (global), modifiers TC and 26
					 shall be used when appropriate.
Evaluation and Management
					 Codes
: Evaluation and Management codes 99201-99215 are to be used
					 for evaluations and management only. The rates are posted on the Physician Fee
					 Schedule under MaineCare UCR at:
https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx?RootFolder=%2FProvider%20Fee%20Schedules%2FMaineCare%20UCR&FolderCTID=0x012000264D1FBA0C2BB247BF40A2C571600E81&View=%7B69CEE1D4%2DA5CC%2D4DAE%2D93B6%2D72A66DE366E0%7D
The Department is seeking and anticipates receiving
					 CMS approval for this Section. Pending approval, the following rule will be
					 applied.
FEE SCHEDULE
The following Fee Schedule represents the only procedure
					 codes chiropractors may use to bill MaineCare. The member can be billed for any
					 non-covered service only if the member has been informed that he/she is liable
					 for payment for non-covered services. This must be done prior to the provision
					 of services. Documentation of the prior notification must be included in the
					 member's records.
ALLOWED AGE
PROC CODE
Modifier
DESCRIPTION
MAXIMUM ALLOWANCE
All Ages
72020
Radiologic Examination, Spine, Single View, Specify
								Level
$14.76
All Ages
72020
26
Radiologic Examination, Spine, Single View, Specify
								Level (Professional Component)
$5.26
All Ages
72020
TC
Radiologic Examination, Spine, Single View, Specify
								Level (Technical Component)
$9.49
All Ages
72040
Radiologic Examination, Spine, Cervical; Two or
								Three Views
$22.86
All Ages
72040
26
Radiologic Examination, Spine, Cervical; Two or
								Three Views (Professional Component)
$7.48
All Ages
72040
TC
Radiologic Examination, Spine, Cervical; Two or
								Three Views (Technical Component)
$15.38
All Ages
72050
Radiologic Examination, Spine, Cervical; Four or
								Five Views
$32.37
All Ages
72050
26
Radiologic Examination, Spine, Cervical; Four or
								Five Views (Professional Component)
$10.43
All Ages
72050
TC
Radiologic Examination, Spine, Cervical; Four or
								Five Views (Technical Component)
$21.94
All Ages
72052
Radiologic Examination, Spine, Cervical; Six or
								More Views
$40.52
All Ages
72052
26
Radiologic Examination, Spine, Cervical; Six or
								More Views (Professional Component)
$12.27
All Ages
72052
TC
Radiologic Examination, Spine, Cervical; Six or
								More Views (Technical Component)
$28.25
All Ages
72070
Radiologic Examination, Spine; Thoracic, Two
								Views
$21.06
All Ages
72070
26
Radiologic Examination, Spine; Thoracic, Two Views
								(Professional Component)
$7.48
All Ages
72070
TC
Radiologic Examination, Spine; Thoracic, Two Views
								(Technical Component)
$13.57
All Ages
72072
Radiologic Examination, Spine, Thoracic, Three
								Views
$23.88
All Ages
72072
26
Radiologic Examination, Spine, Thoracic, Three
								Views (Professional Component)
$7.48
All Ages
72072
TC
Radiologic Examination, Spine, Thoracic, Three
								Views (Technical Component)
$16.40
All Ages
72074
Radiologic Examination, Spine, Thoracic; Minimum of
								Four Views
$27.84
All Ages
72074
26
Radiologic Examination, Spine, Thoracic; Minimum of
								Four Views (Professional Component)
$7.48
All Ages
72074
TC
Radiologic Examination, Spine, Thoracic; Minimum of
								Four Views (Technical Component)
$20.36
All Ages
72080
Radiologic Examination, Spine, Thoracolumbar
								Junction, Minimum of Two Views
$21.96
All Ages
72080
26
Radiologic Examination, Spine, Thoracolumbar
								Junction, Minimum of Two Views (Professional Component)
$7.48
All Ages
72080
TC
Radiologic Examination, Spine, Thoracolumbar
								Junction, Minimum of Two Views (Technical Component)
$14.48
All Ages
72081
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); one view
$25.40
All Ages
72081
26
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); One view (Professional Component)
$9.14
All Ages
72081
TC
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); One View (Technical Component)
$16.27
All Ages
72082
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Two or Three Views
$40.69
All Ages
72082
26
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Two or Three Views (Professional Component)
$11.08
All Ages
72082
TC
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Two or Three Views (Technical Component)
$29.61
All Ages
72083
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Four or Five Views
$44.23
All Ages
72083
26
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Four or Five Views (Professional Component)
$12.08
All Ages
72083
TC
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Four or Five Views (Technical Component)
$32.14
All Ages
72084
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Minimum of Six Views
$52.86
All Ages
72084
26
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Minimum of Six Views (Professional Component)
$14.05
All Ages
72084
TC
Radiologic examination, spine, entire thoracic and
								lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis
								evaluation); Minimum of Six Views (Technical Component)
$38.82
All Ages
72100
Radiologic Examination, Spine; Lumbosacral; Two or
								Three Views
$23.99
All Ages
72100
26
Radiologic Examination, Spine; Lumbosacral; Two or
								Three Views (Professional Component)
$7.48
All Ages
72100
TC
Radiologic Examination, Spine; Lumbosacral; Two or
								Three Views (Technical Component)
$16.51
All Ages
72110
Radiologic Examination, Spine, Lumbosacral; Minimum
								of Four Views
$33.50
All Ages
72110
26
Radiologic Examination, Spine, Lumbosacral; Minimum
								of Four Views (Professional Component)
$10.43
All Ages
72110
TC
Radiologic Examination, Spine, Lumbosacral; Minimum
								of Four Views (Technical Component)
$23.07
All Ages
72114
Radiologic Examination, Spine, Lumbosacral;
								Complete, Including Bending Views, minimum of 6 views
$43.67
All Ages
72114
26
Radiologic Examination, Spine, Lumbosacral;
								Complete, Including Bending Views, minimum of 6 views (Professional
								Component)
$12.27
All Ages
72114
TC
Radiologic Examination, Spine, Lumbosacral;
								Complete, Including Bending Views, minimum of 6 views (Technical
								Component)
$31.41
All Ages
72120
Radiologic Examination, Spine; Lumbosacral; Bending
								Views Only, Two or Three Views
$29.87
All Ages
72120
26
Radiologic Examination, Spine; Lumbosacral; Bending
								Views Only, Two or Three Views (Professional Component)
$7.48
All Ages
72120
TC
Radiologic Examination, Spine; Lumbosacral; Bending
								Views Only, Two or Three Views (Technical Component)
$22.39
All Ages
98940
Chiropractic Manipulative Treatment (CMT); Spinal,
								One to Two Regions
$19.40
All Ages
98941
Chiropractic Manipulative Treatment (CMT); Spinal,
								Three to Four Regions
$19.40
All Ages
98942
Chiropractic Manipulative Treatment (CMT); Spinal,
								Five Regions
$24.23