Fee schedule: Chiropractic services

Chiropractic services

Fee schedule: Chiropractic services
Services included Service code Fee

Initial Visit

V103

$35.43

Continuing Treatment (per visit) V101 $28.98
Home Visit V102 $36.23
Acupuncture (per visit) 5130 $44.96

Note: Acupuncture (per visit)

  • An initial trial of up to six treatments may be allowed.
  • Requests for extensions must be submitted in writing and pre-approved by the WSIB.
  • Must be delivered by a regulated health professional with appropriate training completed at an educational facility that offers a certification program in acupuncture and adheres to the standards of the College of Chiropractors of Ontario.

Radiographic examinations

Note:

  • All fees listed apply to unilateral examinations unless otherwise specified.
  • When only one extremity is injured, no additional charge should be made for comparison x-rays of the opposite side.
  • In lumbar or lumbosacral spine (X028) does not include the entire sacrum. An examination of the sacrum may be carried out and claimed only when specifically required.
  • "Views" and "films" are considered the same.

Radiographic examinations

Spine & Pelvis

Fee schedule: Cervical spine
Services included Service code Fee
Two or three views X025 $35.20
Four or five views X202 $45.80
Six or more views X203 $55.64
Fee schedule: Thoracic spine
Services included Service code Fee

Two views

X027

$32.85

Three or more views X204 $43.23
Fee schedule: Lumbar or lumbosacral spine
Services included Service code Fee

Two or three views

X028

$35.20

Four or five views X205 $45.80
Six or more views X206 $55.86
Fee schedule: Entire spine
Services included Service code Fee

(Scoliosis series) minimum of four views

X032

$76.67

Orthoroentgenogram (3 ft. film) – single view X033 $32.63
Two or more views X031 $43.98
Fee schedule: Sacrum and/or coccyx
Services included Service code Fee

Two views

X034

$32.96

Three or more views X207 $43.23
Fee schedule: Sacro-iliac joints
Services included Service code Fee

Two or three views

X035

$32.63

Four or more views X208 $43.02
Fee schedule: Pelvis and/or hip(s)
Services included Service code Fee

One view

X036

$21.93

Two views (e.g. A.P. and frog view, both hips or A.P. both hips plus lateral each hip) X037 $38.41

Three or more views (e.g. pelvis and sacro-iliac joints orA.P. both hips plus lateral each hip)

X038 $43.88

Upper Extremities

Fee schedule: Clavicle

Services included Service code Fee

Two views

X045

$21.93

Three or more views X209 $32.75
Fee schedule: Acromioclavicular joints (bilateral) with or without weighted distraction
Services included Service code Fee

Two views

X046

$32.63

Three or more views X201 $43.76
Fee schedule: Sternoclavicular joints (bilateral)
Services included Service code Fee

Two or three views

X047

$26.43

Four or more views X211 $37.35
Fee schedule: Shoulder
Services included Service code Fee

Two views

X048

$26.43

Three or more views X212 $37.35
Fee schedule: Scapula
Services included Service code Fee

Two views

X049

$26.43

Three or more views X047X213 $37.35
Fee schedule: Humerus (incl. one joint)
Services included Service code Fee

Two views

X050

$21.93

Three or more views X214 $32.96
Fee schedule: Elbow
Services included Service code Fee

Two views

X051

$21.93

Three or more views X215 $32.96
Five or more views X216 $43.88
Fee schedule: Forearm (incl. one joint)
Services included Service code Fee

Two views

X052

$21.93

Three or more views X217 $32.96
Fee schedule: Wrist
Services included Service code Fee

Two or three views

X053

$21.93

Four or more views X218 $32.96
Fee schedule: Hand
Services included Service code Fee

Two or three views

X054

$21.93

Four or more views X219 $32.96
Fee schedule: Wrist and Hand
Services included Service code Fee

Two or three views

X055

$34.99

Four or more views X220 $43.71
Fee schedule: Finger or Thumb
Services included Service code Fee

Two views

X056

$16.58

Three or more views X221 $21.93

Lower Extremities

Fee schedule: Hip (unilateral)

Services included Service code Fee

Two or more views

X060

$32.63

Fee schedule: Femur (incl. one joint)
Services included Service code Fee

Two views

X063

$21.93

Three or four views X223 $32.96
Fee schedule: Knee (incl. patella)
Services included Service code Fee

Two views

X065

$21.93

Three or four views X224 $32.96
Five or more views X225 $43.88
Fee schedule: Tibia and Fibula (incl. one joint)
Services included Service code Fee

Two views

X066

$21.93

Three or more views X226 $32.96
Fee schedule: Ankle
Services included Service code Fee

Two or three views

X067

$21.93

Four or more views X227 $32.96
Fee schedule: Calcaneus
Services included Service code Fee

Two views

X068

$21.93

Three or more views X228 $32.96
Fee schedule: Foot
Services included Service code Fee

Two or three views

X069

$21.93

Three or more views X229 $32.96
Fee schedule: Toe
Services included Service code Fee

Two views

X072

$16.58

Three or more views X230 $21.93
Fee schedule: Leg length
Services included Service code Fee

Orthoroentgenogram

X064

$32.63

Chest

Fee schedule: Ribs
Services included Service code Fee
Two or more views X039 $26.32

Reports

Fee schedule: Chiropractic reports
Services included Service code Fee
Health Professional's Report (paper submission) 8M1 $40.00
Health Professional's Report (electronic submission) 8M1E $50.00
Health Professional's Continuity Report 8R $33.00
Health Professional's Progress Report (paper submission) 26M1 $35.00
Health Professional's Progress Report (electronic submission) 26M1E $40.00
Narrative Progress Report 26 $23.54

Functional Abilities Form for Planning Early and Safe Return to Work

FAF

$45.00
X-ray Report C642 $23.54
Complex Report/Requests for health information C649 $112.10

Review of patients clinical records/clinical literature

(per 15 minute unit or major part there of)

C651

$56.05

Note: Functional Abilities Form for Planning Early and Safe Return to Work

  • Request for the completion of the form must be initiated by either the worker or employer.
  • Do not include clinical/diagnostic information on the form.

Other services

Fee schedule: Other chiropractic services
Services included Service code Fee
In-office interview with WSIB representative C645 $29.15

Telephone Consultation with treating health professional:

N/A

$45.00

Note: Telephone Consultation with treating health professional

  • Call must be initiated by the WSIB to treating health professional.
  • Paid at a flat rate fee regardless of the duration of the discussion.
  • A clinical report is not to be billed in addition to the telephone consultation.
Fee schedule: Photocopies of clinical reports
Services included Service code Fee
One to five pages C650 $23.54
Each additional page C650 $1.12

Overview

Chiropractic overview
Services included Service code When to submit
Health Professional's Report 8M1/8M1E

This form should be completed and submitted to the WSIB in all cases where the worker has identified the injury/illness as work-related. Submit only one Form 8 for each worker. This report must not be used as a progress report.

Health Professional's Continuity Report 8R This form should be completed and submitted to the WSIB in all cases where the worker has identified a recurrence of a previous work-related injury/illness.
Health Professional's Progress Report 26M1/26M1E

The WSIB sends this form to the worker when a progress report is required. When a worker provides this form, complete it and submit it to the WSIB.

Narrative Progress Report 26 A progress report may be provided on your letterhead in cases when you become aware of new and significant information relevant to the worker’s workplace injury/illness.
Functional Abilities Form for Planning Early and Safe Return to Work FAF

This form is to be provided to you by either the worker or employer. Health professionals do not initiate the completion of this form. Do not include clinical or diagnostic information on the form.

X-ray Report C642 An X-ray report covering several radiological examinations is considered one report. Submit X-ray reports only when specifically requested by the WSIB.
In-Office Interview C645 This will be paid only when a WSIB representative (i.e. investigator) requests an appointment with you to discuss the worker’s injury/illness.
Request for Health Information/Complex Report C649 A complex report is requested by the WSIB when a worker has been treated for a substantial period of time without resolution. The WSIB will indicate the specific information required via the Request for Health Information Form.
Photocopies C650 Photocopies of reports must be requested by the WSIB. Only provide copies of your own clinical records. Copies of other health professionals’ reports are not to be submitted. The WSIB will request the necessary reports from other health professionals involved in the worker’s claim.
Review of Patient Records/Clinical Literature C651 The WSIB may request a narrative report when detailed information regarding the worker’s past records and/or clinical literature relevant to the worker’s claim is required. The WSIB will specify the period in question and the in- formation required. Usually there is no concurrent clinical assessment of the worker required.
Chiropractor’s Treatment Extension Request  

Complete this form in cases where the worker requires treatment beyond the initial allowed treatment period. To ensure continuity of treatment, submit the request at least four weeks prior to the completion of the initial treatment period.

Additional notes:

  • No fee is paid for the completion of the Chiropractor’s Treatment Extension Request form.
  • For the Health Professional's Report, on the worker’s initial visit, ONLY the Form 8 will be paid. A Functional Abilities (FAF) will not be paid if completed on the same day.
  • For the Functional Abilities Form for Planning Early and Safe Return to Work form, on the worker’s initial visit, ONLY the Form 8 will be paid. A Functional Abilities (FAF) will not be paid if completed on the same day.