Appendix 1 — Procedure Code and Copayment Table for Chiropractic Services
The following table lists the current Medicaid-allowed procedure codes, descriptions, and copayment amounts for covered chiropractic services. Consult the Chiropractic Services Maximum Allowable Fee Schedule for maximum allowable fees. The following charts are periodically revised in Wisconsin Medicaid and BadgerCare Updates.
| Procedure Code |
Description |
Copayment |
|---|---|---|
|
L0120 |
Cervical, flexible, nonadjustable (foam collar) |
$1.00 |
|
L0140 |
Cervical, semi-rigid, adjustable (plastic collar) |
$2.00 |
|
L0210 |
Thoracic, rib belt |
$1.00 |
|
L0500 |
Lumbar-sacral-orthosis (LSO), flexible, (lumbo-sacral support) |
$3.00 |
|
L0600 |
Sacroiliac, flexible (sacroiliac surgical support) |
$3.00 |
|
72010 |
Radiologic examination, spine, entire, survey study, anteroposterior and lateral |
$3.00 |
|
72020 |
Radiologic examination, spine, single view, specify level |
$3.00 |
|
72040 |
Radiologic examination, spine, cervical; two or three views |
$3.00 |
|
72050 |
minimum of four views |
$3.00 |
|
72052 |
complete, including oblique and flexion and/or extension studies |
$3.00 |
|
72070 |
Radiologic examination, spine; thoracic, two views |
$3.00 |
|
72100 |
Radiologic examination, spine, lumbosacral; two or three views |
$3.00 |
|
72110 |
minimum of four views |
$3.00 |
|
72120 |
Radiologic examination, spine, lumbosacral, bending views only, minimum of four views |
$3.00 |
|
72200 |
Radiologic examination, sacroiliac joints; less than three views |
$1.00 |
|
72202 |
three or more views |
$3.00 |
|
72220 |
Radiologic examination, sacrum and coccyx, minimum of two views |
$3.00 |
|
73000 |
Radiologic examination; clavicle, complete |
$1.00 |
|
73010 |
scapula, complete |
$3.00 |
|
73020 |
Radiologic examination, shoulder; one view |
$1.00 |
|
73030 |
complete, minimum of two views |
$3.00 |
|
73050 |
Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction |
$3.00 |
|
73060 |
humerus, minimum of two views |
$1.00 |
|
73070 |
Radiologic examination, elbow; two views |
$1.00 |
|
73080 |
complete, minimum of three views |
$1.00 |
|
73500 |
Radiologic examination, hip, unilateral; one view |
$1.00 |
|
73510 |
complete, minimum of two views |
$3.00 |
|
73520 |
Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis |
$3.00 |
|
73540 |
Radiologic examination, pelvis and hips, infant or child, minimum of two views |
$0.00 |
|
73550 |
Radiologic examination, femur, two views |
$3.00 |
|
73560 |
Radiologic examination, knee; one or two views |
$1.00 |
|
73562 |
three views |
$1.00 |
|
73564 |
complete, four or more views |
$1.00 |
|
81000 |
Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy |
$0.50 |
|
98940 |
Chiropractic manipulative treatment (CMT); spinal, one to two regions |
$1.00 |
|
98941 |
spinal, three to four regions |
$1.00 |
|
98942 |
spinal, five regions |
$1.00 |
|
99201 |
Office or other outpatient visit for the evaluation and management of a
new patient, which requires these three key components:
|
$1.00 |
Next — Appendix 2 — Place of Service Codes for Chiropractic Services
Previous — Claims Submission, Reimbursement, Maximum Allowable Fees
Chiropractic Services Handbook
PHC 1306, October 2004