HI 00610.080 Coverage of Chiropractic Services
A. Manual manipulation
Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of hands only. Thus, adjunctive therapies performed by a chiropractor such as diathermy, ultrasound, traction, etc. are not covered. In addition, no reimbursement may be made for X-rays or other diagnostic services such as laboratory tests furnished by the chiropractor nor will additional charges be recognized for history-taking or physical examinations.
The word “correction” may be used in lieu of treatment. Also, a number of different terms composed of the following words may be used to describe “manual manipulation” as defined above:
Spine or spinal adjustment by manual means
Spine or spinal manipulation
Vertebral manipulation or adjustment
In any case where the term(s) used to describe the service performed suggest that it may not have been treatment by means of manual manipulation, the carrier refers the claim for professional review and interpretation.
B. Subluxation demonstrated by x-ray
The manual manipulation must be directed to the spine for the purpose of correcting a subluxation demonstrated by X-ray to exist. For Medicare “subluxation” means an incomplete dislocation, off-centering, misalignment, fixation or abnormal spacing of the vertebrae anatomically which must be demonstrable on an X-ray film to individuals trained in the reading of X-rays.
The documenting X-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment (no more than 3 months prior to the date a course of treatment was initiated for an acute condition, and no more than 12 months prior to the initiation of a course of treatment for a chronic condition.) In certain cases of chronic subluxation (e.g., scoliosis) an older X-ray may be accepted provided the beneficiary's health record indicates the condition has existed longer than 12 months and there are reasonable grounds for the conclusion that the condition is permanent.
C. Necessity for treatment
The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment and the 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 to provide therapeutic grounds for chiropractic manipulative treatment. On the other hand, most other diseases and pathological disorders do not. Examples of the latter include rheumatoid arthritis, muscular dystrophy, multiple sclerosis, pneumonia, and emphysema.
D. Treatment parameters
The chiropractor is afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation problems may require as much as 3 months of treatment but some require very little treatment. In the first several days treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.
Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already “set” and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.
Carriers develop parameters under which an extension in the course of treatment could be supported based on special documentation of need and under which coverage will be finally terminated for lack of reasonable expectation that continuation of treatment could be beneficial.
Some chiropractors use an “intensive care” concept of treatment. Under this approach multiple daily visits (as many as four or five in a single day) are given in the office of clinic and so-called room or ward fees are charged since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare is limited to not more than one treatment per day unless documentation of the reasonableness and necessity for additional treatment is submitted with the claim.