Special Update

Chiropractic Services – Changes effective April 1, 2000

Guidelines for chiropractic services performed on or after April 1, 2000 have been redefined in the following specific terms:

1. A 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.
2. For dates of service from January 1, 2000, the subluxation may be demonstrated by (a) x-ray or (b) physical examination.

(Prior to January 1, 2000, the subluxation must be demonstrated by x-ray. This x-ray should be available for review. If the beneficiary refuses to have an x-ray, submit the claim using the appropriate chiropractic manipulation code with modifier GX (service not covered by Medicare) and the claim will be denied as a technical denial.)

1. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. 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 is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.
2. When demonstrated by Physical Examination, evaluation of musculoskeletal/nervous system is used to identify:

• Pain/tenderness evaluated in terms of location, quality, and intensity;
• Asymmetry/misalignment identified on a sectional or segmental level;
• Range of motion abnormality (changes in active passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility; and
• Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.

1. At least two of the criteria above are required; one of which must be asymmetry/misalignment or range of motion abnormality.
2. The history recorded in the patient record should include the following:

• Symptoms causing patient to seek treatment;
• Family history if relevant;
• Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
• Mechanism of trauma;
• Quality and character of symptoms/problem;
• Onset, duration, intensity, frequency, location and radiation of symptoms;
• Aggravating or relieving factors; and
• Prior interventions, treatments, medications, secondary complaints.

3. Initial Visits – The following documentation requirements apply, whether the subluxation is demonstrated by x-ray or physical examination:
1. History as stated above.
2. Description of the present illness including:

• Mechanism of trauma;
• Quality and character of symptoms/problem;
• Onset, duration, intensity, frequency, location, and radiation of symptoms;
• Aggravating or relieving factors;
• Prior interventions, treatments, medications, secondary complaints; and
• Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

1. Evaluation of musculoskeletal/nervous system through physical examination
2. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.
3. Treatment Plan: The treatment plan should include the following:

• Recommended level of care (duration and frequency of visits);
• Specific treatment goals; and
• Objective measures to evaluate treatment effectiveness.

1. Date of initial treatment (This date or the date of exacerbation of the existing condition must be entered in Box 14 of the HCFA 1500 form.)

4. Subsequent visits - The following documentation requirements apply, whether the subluxation is demonstrated by x-ray or physical examination:
1. History:

• Review of chief complaint;
• Changes since last visit;
• System review if relevant.

1. Physical exam

• Exam of area of spine involved in diagnosis;
• Assessment of change in patient condition since last visit;
• Evaluation of treatment effectiveness

1. Documentation of treatment given on day of visit

5. Necessity for chiropractic treatment:
1. The patient must have a significant health problem in the form of a neuromusculoskeletal condition. The manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam, as described above.

•  result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered.

1. Maintenance Therapy – A treatment plan that seeks to prevent disease, promote health and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition is not a Medicare benefit. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.
2. Contraindications – Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement.

A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. The following are relative contraindications to dynamic thrust:

• Articular mobility and circumstances where the stability of the joint is uncertain;
• Severe demineralization of bone;
• Benign bone tumors (spine);
• Bleeding disorders and anticoagulant therapy; and
• Radiculopathy with progressive neurological signs

Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:

• Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
• Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
• An unstable os odontoideum;
• Malignancies that involve the vertebral column;
• Infection of bones or joints of the vertebral column;
• Signs and symptoms of myelopathy or cauda equina syndrome;
• For cervical spinal manipulation, vertebrobasilar insufficiency syndrome; and
• A significant major artery aneurysm near the proposed manipulation

6. Location of Subluxation: The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made is relation to the part of the spine in which the subluxation is identified:

In addition to the vertebrae and pelvis bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment.

There are two ways to specify the level of the subluxation:

• The exact bones may be listed, for example: C5, 6, etc.
• The area may suffice if it implies only certain bones such as: occipito-atlantal (occiput and C1 (atlas)), lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).
  
  
Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:
• Off-centered
• Misalignment
• Malpositioning

• Spacing:
• Abnormal
• Altered
• Decreased
• Increased

Incomplete dislocation

• Rotation
• Listhesis:
• Antero
• Postero
•  Retro
•  Lateral
•  Spondylo
  
  
• Motion:
• Limited
• Lost
• Restricted
• Flexion
• Extension
• Hyper mobility
• Hypomotility
• Aberrant

Other terms may be used. If they are understood clearly to refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.

7. Treatment guidelines

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration of subluxation within a reasonable and generally predictable period of time.

• Acute subluxation (e.g., strains or sprains) problems may require as many 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 (e.g., loss of joint mobility or other joint problems) 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.
• Some chiropractors have been identified as using 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 or 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 will be limited to not more than one treatment per day unless documentation of the reasonableness and necessity for additional treatment is submitted with the claim.