[Federal Register: January 28, 2005 (Volume 70, Number 18)]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Medicare Program; Demonstration of Coverage of Chiropractic
Services Under Medicare
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
SUMMARY: This notice announces the implementation of a demonstration
mandated under Section 651 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173),
which will expand coverage of chiropractic services under Medicare
beyond the current coverage for manipulation to correct a
neuromusculoskeletal condition. Chiropractors will be permitted to bill
Medicare for diagnostic and other services that a chiropractor is
legally authorized to perform by the State or jurisdiction in which
such treatment is provided. The demonstration will be conducted in four
sites, two urban and two rural; one site in each area type must be a
health professional shortage area (HPSA).
--Medicare per capita claims costs
Any chiropractor that provides services in these geographic areas
will be able to participate in the demonstration. Any beneficiary
enrolled under Medicare Part B, and served by chiropractors practicing
in these sites would be eligible to receive services. Physician
approval would not be required for these services. The statute requires
that the demonstration be budget neutral. We anticipate that the
demonstration will begin in April 2005 and operate for two years.
1. By Mail: Written inquiries regarding this demonstration must be
submitted by mail to the following address:
Centers for Medicare & Medicaid Services, Attn: Sidney Trieger,
Division of Health Promotion and Disease Prevention Demonstrations,
Office of Research, Development, and Information, Centers for Medicare
& Medicaid Services, S3-02-01, 7500 Security Boulevard, Baltimore,
Please allow sufficient time for mailed information to be received
in a timely manner in the event of delivery delays.
2. E-mail: Inquiries may be sent to the following e-mail address:
FOR FURTHER INFORMATION CONTACT: Julie Jones, (410) 786-3039 or Sidney
Trieger, (410) 786-6613.
Section 651 of the Medicare Prescription Drug, Improvement and
Modernization Act of 2003 (MMA) (Pub. L. 108-173) provides for a two-
year demonstration to evaluate the feasibility and advisability of
covering chiropractic services under Medicare. These services extend
beyond the current coverage for manipulation to correct
neuromusculoskeletal conditions typical among eligible beneficiaries,
and would cover diagnostic and other services that a chiropractor is
legally authorized to perform by the State or jurisdiction in which the
treatment is provided. Physician approval would not be required for
these services. The demonstration must be budget neutral and will be
conducted in four sites, two rural and two urban; one site of each area
type must be a health professional shortage area (HPSA).
Current Medicare coverage for chiropractic care is limited to
manual manipulation of the spine to correct a subluxation, which
chiropractors define as a malfunction of the spine. The three currently
covered CPT codes are 98940 (manipulative treatment, 1-2 regions of the
spine), 98941 (manipulative treatment, 3-4 regions of the spine), and
98942 (manipulative treatment, 5 regions of the spine).
Treatment must be provided for an active subluxation and not for
prevention or maintenance. Treatment of the subluxation must be related
to a neuromusculoskeletal condition where there is a reasonable
expectation of recovery or functional improvement. Chiropractors are
required to document the patient's complaint and establish a treatment
plan, which includes the expected duration and frequency of treatment,
specific goals and measures of effectiveness. This information must be
maintained in the medical record and made available to Medicare upon
request. Patients do not need a medical physician referral for
treatment by a chiropractor under fee-for-service; some Medicare
Advantage (MA) plans may require an enrollee to obtain a referral
before seeing a chiropractor. In addition, some MA plans do not have
chiropractors in their networks and allow osteopaths to provide
II. Provisions of the Notice
A. Covered Services
To determine which services will be covered, we conducted a
literature review of the evidence of the effectiveness of chiropractor
services. We held discussions with the American Chiropractic
Association (ACA) and also reviewed the current coverage of
chiropractor services with the Department of Defense and the Veterans
Administration. In addition, we convened an Open Door Forum in November
2004 to invite comments on our proposed design for the demonstration.
Based on these discussions, the evidence for effectiveness of
chiropractic care, and current Medicare policy, the following
guidelines for the demonstration were developed:
1. Services must be related to active treatment, not maintenance or
prevention. This follows current Medicare coverage for similar
services, such as physical therapy. Medicare does not authorize payment
for maintenance therapies for other providers. We will require that all
claims under the demonstration will have the active therapy (AT)
2. The demonstration will expand the services chiropractors are
allowed to provide in the demonstration only to treatment of
neuromusculoskeletal conditions, but not to other conditions. We have
found no literature that provides conclusive evidence that chiropractic
services are effective for treatment of other diagnoses.
3. Under the demonstration chiropractors can provide plain x-rays,
electromyography (EMG) tests and nerve conduction studies; order
magnetic resonance imaging (MRI) scans and computed tomography (CT)
scans; as well as order or provide laboratory tests (where the
applicable State practice act permits chiropractors to provide these
services). These diagnostic services are related to the diagnosis and
treatment of neuromusculoskeletal conditions. No limits will be imposed
on chiropractors for providing diagnostic services, unless limits exist
for other providers delivering these services.
4. The demonstration will cover CPT code 98943 for extraspinal
manipulation, as it is a recognized procedure for treating
neuromusculoskeletal conditions. It will also expand coverage to
include other services chiropractors are legally allowed to provide and
Medicare currently covers. These procedures include electrotherapy,
ultrasound, transcutaneous electrical nerve stimulation (TENS) therapy,
and other services that are medically necessary for the treatment of
neuromusculoskeletal conditions. Chiropractors delivering these
services will be subject to the same payment policies as other Medicare
clinicians currently delivering these services. These requirements can
be found in the Medicare Benefit Policy Manual 100-2 in Chapter 15,
Sections 220 and 230 and the Medicare Claims Processing Manual 100-4 in
Chapter 4, Section 20 and other manual sections. For example, physical
and occupational therapy services must be identified through the use of
modifiers GP and GO respectively. Chiropractors will also be allowed to
make referrals for these therapy services.
5. Chiropractors would also be reimbursed for evaluation and
management (E&M) services delivered for neuromusculoskeletal
Under the demonstration, chiropractors would be allowed to bill
Medicare for treatment in addition to an E&M visit on the same day the
first time they assess a patient, and thereafter only when they assess
a patient for a new, separate problem not currently being treated. The
current E&M CPT codes will apply.
We will require chiropractors to submit claims for demonstration
services separately from claims for currently covered services (CPT
codes 98940, 98941, and 98942). Chiropractors will have to add
demonstration code 45 to all demonstration claims in order to be
reimbursed for demonstration services.
B. Managed Care Plans
The legislation requires that the same demonstration benefits be
offered under MA plans as for Medicare fee for service beneficiaries.
Because participation of managed care plans is voluntary, we cannot
require plans to participate in the demonstration. We therefore plan to
approach MA plans in the demonstration site areas to determine if they
would offer demonstration services to beneficiaries, but we will not
change the MA plan rates since the demonstration is required to be
C. Payment Rates
The payment rates for demonstration services will be the same as
under the physician fee schedule.
D. Budget Neutrality
The statute requires the Secretary to ensure that the aggregate
payments made under the Medicare program do not exceed the amount that
would have been paid under the Medicare program in the absence of this
Ensuring budget neutrality requires that the Secretary develop a
strategy for recouping funds should the demonstration result in costs
higher than would occur in the absence of the demonstration. We will
first determine over the two-year demonstration whether the
demonstration was budget neutral. If the demonstration is not budget
neutral, we plan to meet the legislative requirements by making
adjustments in the national chiropractor fee schedule to recover the
costs of the demonstration in excess of the amount estimated to yield
budget neutrality. We will assess budget neutrality by determining the
change in costs based on a pre-post comparison of costs and the rate of
change for specific diagnoses that are treated by chiropractors and
physicians in the demonstration sites and control sites. We will not
limit our analysis to reviewing only chiropractor claims because the
costs of the expanded chiropractor services may have an impact on other
A CMS evaluation contractor will conduct the analysis of claims and
budget neutrality. Since it will take approximately two years to
complete the claims analysis, we anticipate that any necessary
reduction will be made in the 2010 and 2011 fee schedules. If we
determine that the adjustment for budget neutrality would be greater
than two percent of the chiropractor fee schedule, we will implement
the adjustment over a two-year period. However, if the adjustment is
less than two percent of the chiropractor fee schedule, we will
implement the adjustment over a one-year period. We will include the
detailed analysis of budget neutrality and the proposed offset in the
2009 Federal Register publication of the physician fee schedule.
We invite comments regarding the appropriate methodology for
determining budget neutrality. Written materials may be submitted by
mail or e-mail to the addresses listed in the ADDRESSES section of this
E. Site Selection
The statute requires that this demonstration be conducted in four
sites--two rural and two urban; one site in each type of area must be a
health professional shortage area (HPSA). We have selected:
• 26 northern counties in Illinois which includes Cook,
Dekalb, DuPage, Grundy, Kane, Kendall, McHenry, Will, Boone, Bureau,
Carroll, Henry, JoDaviess, Kankakee, Lake, LaSalle, Lee, Marshall,
Mercer, Ogle, Putnam, Rock Island, Stark, Stephenson, Whiteside, and
Winnebago, and Scott county in Iowa (urban);
• 17 central HPSA counties in Richmond, Charlottesville,
Lynchburg, and Danville MSAs in Virginia (urban HPSA)--the Virginia
counties include Pittsylvania, Campbell, Appomattox, Nelson,
Buckingham, Fluvanna, Louisa, Caroline, Hanover, New Kent, Henrico,
Richmond City, Goochland, Cumberland, Powhatan, Amelia and Danville
• New Mexico (rural HPSA); and
• Maine (rural).
We first grouped States by Medicare carriers, because we determined
it was important that control and experimental sites should have the
same carriers (since some carriers impose limits on chiropractor claims
they approve). We then determined appropriate sites based on the
• Exclude States with restrictive practice regulations.
• Exclude States that will not have transitioned to the MCS
system in time for the demonstration.
• Exclude States that are ranked in the top or bottom 5
values for two or more of the following six statistics:
--Medicare per capita chiropractic costs
--Per user (patient) chiropractic costs based on carrier data
--Chiropractic service users as a percentage of Part B beneficiaries
--Chiropractors per 10,000 State population
--Chiropractors per 1,000 Part B beneficiaries
• Exclude States among those remaining that are served by a
unique carrier and, thus, would lack a potential comparison site.
• Each carrier group was assessed to determine its ability
to support treatment and comparison groups for one or more types of
• Data was then used to estimate the number of beneficiaries
residing in Urban/Rural and HPSA/non HPSA areas and determine which of
the remaining States could support a demonstration site or sites.
Few States had enough beneficiaries residing in HPSAs to be
considered for one of the HPSA demonstration sites.
III. Collection of Information Requirements
This document does not impose information collection and record-
keeping requirements. Consequently, it does not need to be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995.
Authority: Section 651 of the Medicare Prescription Drug
Improvement and Modernization Act of 2003 (Pub. L. 108-173).
(Catalog of Federal Domestic Assistance Program No. 93.778 and No.
93.774, Medicare--Supplementary Medical Insurance Program)
Dated: December 17, 2004.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 05-1505 Filed 1-27-05; 8:45 am]
BILLING CODE 4120-01-P