Name of Manual - Blue Cross and Blue Shield of Minnesota

Documentation Guides
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Coding Policies and Guidelines (Chiropractic)
The CPT/HCPCS and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be supported
by the documentation in the medical record. Charge slips,
super bills, travel cards, or office ledgers are not considered
supporting documentation for services provided to a patient.
Use of the term IBID and/or the use of quotation marks to
replace or repeat previously documented information is not
acceptable. All information must be in date-sequence order.
Services not documented as indicated are not covered by Blue
Cross. Patients are not financially liable for services that are
denied for inadequate documentation. In addition, chart
documentation should clearly list the name of the practitioner
rendering services to the member, including the names and
credentials of employees providing care under the supervision of a
chiropractor.
Prior Authorization Chiropractic services rendered by Aware Chiropractic Providers
are not subject to prior authorization for members of Blue Cross
and Blue Shield of Minnesota fully insured groups. For Blue Cross
self-insured groups, it is recommended that prior authorization for
chiropractic services will be done after 20 visits. Benefits are
allowable only for services that are medically necessary. Providers
are encouraged to use provider web self-service or BLUELINE to
obtain member benefits prior to beginning services.
Form Required To obtain prior authorization, providers should complete the
Chiropractic Medical Information Request Form, form number
F4355 R12. This form can be found on the Blue Cross web site.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
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