Medicaid-funded alternative treatment for back pain

Updated March, 2019 *Due to restructuring in the database, report won't be updated until September, 2019

  • The percentage of members with a back pain diagnosis who received an alternative treatment service increased from 28% in June 2016 (the month before OHA expanded coverage of alternatives) to 43% in December 2018. 
  • The rates of members receiving alternative treatment are similar across the region. 
  • The most common alternative treatment for back pain is physical therapy, followed by acupuncture. 

Effective July 1, 2016, the Oregon Health Plan expanded coverage for non-pharmacological treatment of back pain.  These treatments include  physical therapy, acupuncture, massage, water therapy, osteopathy, and chiropractic services. This decision was informed by the  biopsychosocial model of pain and evidence that these modalities  have helped people manage their pain with less reliance on medication and costly surgeries. 

Graph 1 shows the percentage of Medicaid members with a back pain diagnosis who received an alternative treatment service during the month the back pain was diagnosed. Graph 2 shows the most common alternative treatments in the fourth quarter of 2018.

Graph showing % members with a back pain diagnosis who receive alternative treatment services


Graph showing most common alternative treatments, Q4 2018

Back pain was defined using ICD-10 codes that OHA has listed as potentially qualifying for alternative treatment. Only primary diagnoses were considered. Alternative treatment was defined using HCPCS codes for physical therapy, acupuncture, massage, water therapy, osteopathy, or chiropractic services. See Appendix for a complete list of codes. 

The data source is Health Share of Oregon member claims. Health Share of Oregon is a Coordinated Care Organization (CCO) serving approximately 310,000 Medicaid members in the tri-county area. 

Denominator: Members with a back pain diagnosis. Members were included in the denominator if they had at least one claim with a primary diagnosis of a type of back pain that would potentially qualify for alternative treatment services. See Appendix for complete list of ICD-10 codes. Members could only be included in the denominator once per month, regardless of their number of claims for back pain. Only paid claims were included.

Numerator: Members with a back pain diagnosis and a claim for an alternative treatment service. Members were included if they were in the denominator AND if they had at least one claim with a procedure code for physical therapy, acupuncture, massage, water therapy, osteopathy, or chiropractic services during the same month of their back pain diagnosis. Members could only be included in the numerator once per month, regardless of their number of claims for alternative treatment. Only paid claims were included.

Limitations. These data capture only the members with a primary diagnosis of back pain.  They do not provide a complete picture of the members who could benefit from pain care services for undiagnosed back pain or other pain diagnosis.  Additionally, these data do not provide information on whether care received improved patient outcomes.  These data do not include commercially insured or uninsured individuals who live with persistent pain and who could benefit from pain care.

ICD-10 Codes for back pain diagnosis:

F45.42, G83.4, G95.0, M24.08, M25.78, M40.00M40.03, M40.04, M40.05, M40.10, M40.12, M40.13, M40.14, M40.15, M40.202, M40.203, M40.204, M40.205, M40.209, M40.292, M40.293, M40.294, M40.295, M40.299, M40.30, M40.35, M40.36, M40.37, M40.40, M40.45, M40.46, M40.47, M40.50, M40.55, M40.56, M40.57, M41.00, M41.02, M41.03, M41.04, M41.05, M41.06, M41.07, M41.08, M41.112, M41.113, M41.114, M41.115, M41.116, M41.117, M41.119, M41.122, M41.123, M41.124, M41.125, M41.126, M41.127, M41.129, M41.20, M41.22, M41.23, M41.24, M41.25, M41.26, M41.27, M41.30, M41.34, M41.35, M41.40, M41.41, M41.42, M41.43, M41.44, M41.45, M41.46, M41.47, M41.50, M41.52, M41.53, M41.54, M41.55, M41.56, M41.57, M41.80, M41.82, M41.83, M41.84, M41.85, M41.86, M41.87, M41.9, M42.00, M42.01, M42.02, M42.03, M42.04, M42.05, M42.06, M42.07, M42.08, M42.09, M42.11, M42.12, M42.13, M42.14, M42.15, M42.16, M42.17, M42.18, M42.19, M42.9, M43.00, M43.01, M43.02, M43.03, M43.04, M43.05, M43.06, M43.07,M43.08, M43.09, M43.10, M43.11, M43.12, M43.13, M43.14, M43.15, M43.16, M43.17, M43.18, M43.19, M43.20, M43.21, M43.22, M43.23, M43.24, M43.25, M43.26, M43.27, M43.28, M43.3, M43.4, M43.5X2, M43.5X3, M43.5X4, M43.5X5, M43.5X6, M43.5X7, M43.5X8, M43.5X9, M43.8X1, M43.8X2, M43.8X3, M43.8X4, M43.8X5, M43.8X6, M43.8X7, M43.8X8, M43.8X9, M43.9, M45.0, M45.1, M45.2, M45.3, M45.4, M45.5, M45.6, M45.7, M45.8, M45.9, M46.1, M46.40, M46.41, M46.42, M46.43, M46.44, M46.45, M46.46, M46.47, M46.48, M46.49, M46.50, M46.51, M46.52, M46.53, M46.54, M46.55, M46.56, M46.57, M46.58, M46.59, M46.80, M46.81, M46.82, M46.83, M46.84, M46.85, M46.86, M46.87, M46.88, M46.89, M46.90, M46.91, M46.92, M46.93, M46.94, M46.95, M46.96, M46.97, M46.98, M46.99, M47.011, M47.012, M47.013, M47.014, M47.015, M47.016, M47.019, M47.021, M47.022, M47.029, M47.10, M47.11, M47.12, M47.13, M47.14, M47.15, M47.16, M47.20, M47.21, M47.22, M47.23, M47.24, M47.25, M47.26, M47.27, M47.28, M47.811, M47.812, M47.813, M47.814, M47.815, M47.816, M47.817, M47.818, M47.819, M47.891, M47.892, M47.893,M47.894, M47.895, M47.896, M47.897, M47.898, M47.899, M47.9, M48.00, M48.01, M48.02, M48.03, M48.04, M48.05, M48.06, M48.07, M48.08, M48.10, M48.11, M48.12, M48.13, M48.14, M48.15, M48.16, M48.17, M48.18, M48.19, M48.20, M48.21, M48.22, M48.23, M48.24, M48.25, M48.26, M48.27, M48.30, M48.31, M48.32, M48.33, M48.34, M48.35, M48.36, M48.37, M48.38, M48.8X1, M48.8X2, M48.8X3, M48.8X4, M48.8X5, M48.8X6, M48.8X7, M48.8X8, M48.8X9, M48.9, M49.80, M49.81, M49.82, M49.83, M49.84, M49.85, M49.86, M49.87, M49.88, M49.89, M50.00, M50.01, M50.020, M50.021, M50.022, M50.023, M50.03, M50.10, M50.11, M50.120, M50.121, M50.122, M50.123, M50.13, M50.20, M50.21, M50.220, M50.221, M50.222, M50.223, M50.23, M50.30, M50.31, M50.320, M50.321, M50.322, M50.323, M50.33, M50.80, M50.81, M50.820, M50.821, M50.822, M50.823, M50.83, M50.90, M50.91, M50.920, M50.921, M50.922, M50.923, M50.93, M51.04, M51.05, M51.06, M51.14, M51.15, M51.16, M51.17, M51.24, M51.25, M51.26, M51.27, M51.34, M51.35, M51.36, M51.37, M51.44, M51.45, M51.46, M51.47, M51.84, M51.85, M51.86, M51.87, M51.9, M53.2X1, M53.2X2, M53.2X3, M53.2X4, M53.2X5, M53.2X6, M53.2X7, M53.2X8, M53.2X9, M53.3, M53.80, M53.81, M53.82, M53.83, M53.84, M53.85, M53.86, M53.87, M53.88, M53.9, M54.00, M54.01, M54.02, M54.03, M54.04, M54.05, M54.06, M54.07, M54.08, M54.09, M54.10, M54.11, M54.12, M54.13, M54.14, M54.15, M54.16, M54.17, M54.18, M54.2, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M54.5, M54.6, M54.81, M54.89, M54.9, M62.830, M96.1, M96.2, M96.3, M96.4, M96.5, M99.00, M99.01, M99.02, M99.03, M99.04, M99.05, M99.06, M99.07, M99.08, M99.09, M99.20, M99.21, M99.22, M99.23, M99.24, M99.25, M99.26, M99.27, M99.28, M99.29, M99.30, M99.31, M99.32, M99.33, M99.34, M99.35, M99.36, M99.37, M99.38, M99.39, M99.40, M99.41, M99.42, M99.43, M99.44, M99.45, M99.46, M99.47, M99.48, M99.49, M99.50, M99.51, M99.52, M99.53, M99.54, M99.55, M99.56, M99.57, M99.58, M99.59, M99.60, M99.61, M99.62, M99.63, M99.64, M99.65, M99.66, M99.67, M99.68, M99.69, M99.70, M99.71, M99.72, M99.73, M99.74, M99.75, M99.76, M99.77, M99.78, M99.79, M99.81, M99.82, M99.83, M99.84, Q06.0, Q06.1, Q06.2, Q06.3, Q06.8, Q06.9, Q67.5, Q68.0, Q76.0, Q76.1, Q76.2, Q76.3, Q76.411, Q76.412, Q76.413, Q76.414, Q76.415, Q76.419, Q76.425, Q76.426, Q76.427, Q76.428, Q76.429, Q76.49, S13.0XXA, S13.0XXD, S13.4XXA, S13.4XXD, S13.8XXA, S13.8XXD, S13.9XXA, S13.9XXD, S16.1XXA, S16.1XXD, S23.0XXA, S23.0XXD, S23.100A, S23.100D, S23.101A, S23.101D, S23.110A, S23.110D, S23.111A, S23.111D, S23.120A, S23.120D, S23.121A, S23.121D, S23.122A, S23.122D, S23.123A, S23.123D, S23.130A, S23.130D, S23.131A, S23.131D, S23.132A, S23.132D, S23.133A, S23.133D, S23.140A, S23.140D, S23.141A, S23.141D, S23.142A, S23.142D, S23.143A, S23.143D, S23.150A, S23.150D, S23.151A, S23.151D, S23.152A, S23.152D, S23.153A, S23.153D, S23.160A, S23.160D, S23.161A, S23.161D, S23.162A, S23.162D, S23.163A, S23.163D, S23.170A, S23.170D, S23.171A, S23.171D, S23.3XXA, S23.3XXD, S23.8XXA, S23.8XXD, S23.9XXA, S23.9XXD, S33.0XXA, S33.0XXD, S33.100A, S33.100D, S33.101A, S33.101D, S33.110A, S33.110D, S33.111A, S33.111D, S33.120A, S33.120D, S33.121A, S33.121D, S33.130A, S33.130D, S33.131A, S33.131D, S33.140A, S33.140D, S33.141A, S33.141D, S33.5XXA, S33.5XXD, S33.8XXA, S33.8XXD, S33.9XXA, S33.9XXD, S34.3XXA, S34.3XXD, S39.092A, S39.092D, S39.82XA, S39.82XD, S39.92XA, S39.92XD, Z47.82

Procedure codes for alternative treatment:

97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97810, 97811, 97813, 97814, 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, S9451