Fee schedule: Chiropractic services

Chiropractic services

Fee schedule: Chiropractic services

Services included	Service code	Fee
Initial Visit	V103	$39.40
Continuing Treatment (per visit)	V101	$32.22
Home Visit	V102	$40.28
Acupuncture (per visit)	5130	$49.98

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.