The Centers for Medicare & Medicaid Services (CMS) requires that medical necessity be documented for the coverage of spinal manual manipulation by Doctors of Chiropractic Medicine.
The patient must have both of the following:
- Have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment
- Have a subluxation of the spine as demonstrated by either an x-ray or physical exam
The manipulative services rendered must have both of the following:
- Have a direct therapeutic relationship to the patient's condition
- Provide reasonable expectation of recovery or improvement of function
Definition of Subluxation
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.
Demonstrating and Documenting Subluxation
The subluxation may be demonstrated and documented by one of two methods, as defined below:
- Demonstrated by X-ray:
- The spinal 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 lasted longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI are acceptable evidence if a subluxation of the spine is demonstrated.
- NOTE: Medicare does not pay for an x-ray performed and/or ordered by a chiropractor. Payment to chiropractic physicians is limited to spinal manual manipulation
- Demonstration by Physical Examination:
- An evaluation of musculoskeletal/nervous system document 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)
- Tissue, tone changes in the characteristics of contiguous, or associated soft tissue, including skin, fascia, muscle and ligament
- To demonstrate and document a subluxation based on physical examination, two of the four criteria mentioned above under physical examination are required, one of which must be asymmetry/misalignment or range of motion abnormality
Signatures in Medical Records
Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner’s first and last name and applicable credentials, e.g., P.A., D.O., or M.D. For more information about signatures, please refer to the article titled 'Medicare Part B Medical Records: Signature Requirements, Acceptable and Unacceptable Practices.'
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