Chiropractic General Coverage and Subluxation

A patient must have significant health problems in the form of a neuro-musculoskeletal condition necessitating treatments and the manual manipulative services rendered must have a direct therapeutic relationship to the patient's condition. Spinal axis aches, strains, sprains, nerve pains and functional mechanical disabilities of the spine are considered medically necessary therapeutic grounds for chiropractic manipulative treatment.

  • Treatment of the spine is limited specifically by manual manipulation (use of hands), to correct a subluxation
    • Although Medicare does not recognize an extra charge for the device itself (no additional monies will be given), hand held devices are allowed (they must be controlled manually)
  • Treatment should improve, arrest, or retard patient's condition
  • Results should occur within a reasonable and generally predictable time period
  • Extensive or prolonged services:
    • Treatment course must be clearly documented
    • Documentation must reflect need and support continued length of care
  • No other diagnostic/therapeutic service covered when furnished/ordered by chiropractic physician

Coverage Categories

Subluxation (Acute and Chronic)

The level of spinal subluxation must bear a direct causal relationship to the patient's symptoms and the symptoms must be directly related to the level of the subluxation that has been diagnosed.

Medicare definition: Subluxation is defined as a motion segment in which alignment, movement integrity and or physiological function of the spine are altered although contact between joint surfaces remains intact. Subluxation may be demonstrated by an x-ray or physical examination

Specify one of the following subluxation levels:

  • List exact bones involved such as: C2, L5, etc
  • List area if it implies certain bones such as: Lumbo-sacra, Sacro-iliac
  • Be sure to reflect this in your treatment notes

Acceptable Descriptive Terms (Not an all inclusive list)

  • Off centered
  • Misalignment
  • Malpositioning
  • Incomplete dislocation
  • Rotation
  • Spacing - Abnormal, altered, decreased, increased
  • Motion - Limited, lost, restricted, flexion, extension, hyper mobility, hypomobility, aberrant

X-Ray Demonstration

  • X-ray is not required to demonstrate subluxation; however, may be used if chiropractor chooses
  • X-ray should be taken no more than 12 months prior to initiation of treatment or 3 months following initiation of treatment
  • Previous CT scan and/or MRI acceptable
  • X-ray must be maintained by the referring physician

Ordering/Referring

Chiropractors are only able order or refer for services within scope of practice (i.e. to another chiropractor for manipulations)

Chiropractors cannot:

  • Order or refer for CT, PET, or MRI scans,
  • Order or refer for durable medical equipment,
  • Order prescriptions, or
  • Order laboratory services

Medicare does not cover or reimburse for x-rays ordered or taken by a Chiropractor

  • X-ray must be ordered by MD, DO, NPP

Reasonable and Necessary Services

Treatment must demonstrate significant health problem of neuromusculoskeletal condition

  • Simply indicating a statement of ‘pain' is insufficient; pain location must be described
  • There must be a direct therapeutic relationship to condition
  • Is there a reasonable expectation of recovery?
    • arrest / retard deterioration in condition
    • within a reasonable and predictable period of time
  • Be sure the medical necessity is defined - Social Security Act, Chapter 18, Section 1862

The below is not all inclusive.

  • Yes: spinal aches, strains, sprains, nerve pain, functional mechanical disabilities of spine
  • No: rheumatoid arthritis, muscular dystrophy, multiple sclerosis, pneumonia, emphysema
Last Updated Nov 06 , 2024