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Medicare Documentation Requirements: The Hurdle That Continues to Block Our Progress

Medicare Documentation Requirements:
The Hurdle That Continues to Block Our Progress

The Chiro.Org Blog

SOURCE:   Dynamic Chiropractic ~ April 9, 2012

By David Seaman, DC, MS, DABCN,
Albert J. Luce, DC and
Anthony Hamm, DC, FACO, DABFP

At present, the chiropractic profession has difficulty being compliant with Medicare documentation requirements. The 2009 report from the Office of the Inspector General reported the following: “Distinct from the undocumented claims, 83 percent of reviewed chiropractic claims failed to meet one or more of the documentation requirements.

Concerning treatment, file reviewers reported that only 76 percent contained some form of treatment plan, 43 percent lacked treatment goals, 17 percent lacked objective measures, and 15 percent lacked the recommended level of care.” [1]

In January 2011, the California Chiropractic Association reported the following on its Web site: [2] “Palmetto GBA has released the results of its review of chiropractic Medicare claims and found an “unacceptable” error rate of 68 percent for Northern California and 77 percent for Southern California. These results are very troubling, as Congressional leaders have threatened to remove chiropractic from Medicare if the profession [does] not improve its billing practices.”

Perhaps two primary issues may be at work. Either an inaccurate message is being delivered to chiropractors regarding appropriate Medicare documentation requirements and/or chiropractors are misinterpreting the message. Let’s attempt to clear up some of the confusion, outline documentation requirements based on several Medicare publications, and provide a flow chart for easy visualization of the required process.


What Does Medicare Want?

The rules for Medicare are spelled out in section 240 of chapter 15 of the Medicare Benefit Policy Manual [3] and in your local carrier’s or administrator’s Local Coverage Determination (LCD). The terminology is generally consistent; however, it can be confusing based on how the language is misinterpreted by chiropractors and those who teach documentation and coding seminars.

Contrary to what many believe, Medicare documentation is not subluxation-based, even though parts of section 240 can mislead one in this direction. Why do we say this? Because “subluxation-based” to chiropractors is a different concept compared to subluxation-based to Medicare, and this fact is clearly spelled out in the rules.

Subluxation-based chiropractors view the adjustment of the asymptomatic spine as an acceptable practice. However, this is not the case for Medicare – for Medicare, subluxation is synonymous with a painful neuromusculoskeletal condition of the spine that disables the patient from engaging in routine functional activities of daily living. In the context of treating Medicare patients, consider the following statements from various LCDs throughout the United States.

From the Florida LCD:   “Chiropractic services involve manual manipulation of the spine by a licensed chiropractor to alleviate painful symptomatology due to subluxation of the spine as demonstrated by x-ray or physical exam.”

From the LCD for Upstate New York:   “Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Standardized measurement scales (e.g., Visual Analogue Scale (VAS), Oswestry Disability Questionnaire, and the Quebec Back Pain Disability Scale) may be used to measure improvement or lack thereof.”

From the Trailblazer LCD for Colorado, New Mexico, Oklahoma and Texas:   “For the purpose of Medicare, subluxation means a motion segment in which alignment, movement integrity and/or physiological function of the spine are altered although contact between joint surfaces remains intact. A subluxation usually falls into one of two categories: [1]. Acute, such as strains and sprains. [2]. Chronic, such as loss of joint mobility.”

In a senior citizen, an acute strain/sprain or chronic reduction in joint mobility is always painful. This is why the Florida LCD states that manipulation is to “alleviate painful symptomatology.” This is also why the Upstate New York LCD requires the use of outcome assessment tools that measure pain and disability.

This view is further evidenced by structural and process measures reported through the 2011 CMS Physician Quality Reporting System (PQRS). Two of the three measures that doctors of chiropractic may report are pain assessment and functional outcome assessment. According to PQRS standards, functional outcome deficiencies are defined as “impairment or loss of physical function related to neuromusculoskeletal capacity, including but not limited to restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms and legs, and headaches.”

So, what does Medicare want? Medicare wants us to treat beneficiaries who are disabled by spinal pain. Getting caught up in PART requirements and because “subluxation” is written into section 240 and all LCDs does not change the fact that Medicare is about pain and disability. In short, the chiropractic profession needs to reconcile its historical view of subluxation in the context of current Medicare rules. That congressional leaders are actually thinking about dropping us from Medicare demonstrates this need. [2]

Readjusting Our Notion of Subluxation

In section 240 and all the LCDs, three concepts appear in a fashion that can lead a DC to think they are distinct entities. We read about subluxation, the significant neuromusculoskeletal condition, and the ICD-9 diagnostic code as if they are separate and causally related.

In fact, from an operational perspective, each is referring to the exact same entity: a painful spinal condition that is significant enough to create disability and must be documented in the context of the initial and subsequent visits.

Consider factors that must be documented in the history which relate to the nature of the painful spinal condition:

  • Description of present illness/symptoms causing patient to seek treatment; these symptoms must bear a direct causal relationship to the spine
  • Mechanism of trauma
  • Quality and character
  • Onset, duration, intensity, frequency, location and referral/radiation
  • Aggravating and relieving factors

These history factors are about a painful spinal condition. In fact, all of the key components relevant to Medicare documentation are designed to demonstrate that there is a painful spinal condition present and that it is amenable to chiropractic manipulative treatment. (See Table)

Please notice that the word subluxation does not appear in the table. This is because Medicare documentation is not about “subluxation” in the context that chiropractors perceive it. Rather, as described above, Medicare operationally defines subluxation as a painful spinal condition that creates disability. The sooner we embrace this fact, the sooner we will move toward compliance and hopefully, reimbursement for our full scope of care.



  1. Inappropriate Medicare Payments for Chiropractic Services
    Office of Inspector General, Dept. of Health Human Services, May 2009.

  2. “Palmetto CERT Review Finds ‘Unacceptable’ Chiropractic Medicare Denial Rate.”
    CCA Advantage, January 2011.

  3. Center for Medicare Services.
    Medicare Benefit Policy Manual
    Chapter 15 – Covered Medical and Other Health Services.

  4. Souza TA.
    Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms. 4th Edition.
    Boston: Jones and Bartlett; 2009.

  5. Murphy DR.
    A clinical model for the diagnosis and management of patients with cervical spine syndromes.
    Australas Chiropr Osteopathy, 2004; 12 (2): 57-71

  6. Murphy DR, Hurwitz EL.
    A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.
    BMC Musculoskelet Disord, 2007; 8: 75

  7. Murphy DR, Hurwitz EL, Nelson CF.
    A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature.
    Chiropr Osteopat, 2008; 16: 7

  8. Murphy DR, Hurwitz EL, McGovern EE.
    Outcome of Pregnancy-Related Lumbopelvic Pain Treated According to a Diagnosis-Based Decision Rule: A Prospective Observational Cohort Study
    J Manipulative Physiol Ther. 2009 (Oct); 32 (8): 616–624

  9. Murphy DR, Hurwitz EL, McGovern EE.
    A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up
    J Manipulative Physiol Ther 2009 (Nov); 32 (9): 723–733

  10. Cleland JA, Koppenhaver S.
    Netter’s Orthopedic Clinical Examination: An Evidence-Based Approach. 2nd Edition.
    Philadelphia: Saunders Elsevier; 2011.

3 comments to Medicare Documentation Requirements: The Hurdle That Continues to Block Our Progress

  • Russell Berg D.C.

    Over the past 34 years I have listened to the rhetoric of how chiropractic is gaining more respect within the medical community and how we are gaining parity within the insurance industry. Even with accreditation outside of our profession in chiropractic sports and rehab we have not been able to crack the acceptance to the general public as medicine continues to tighten it’s grip around healthcare. Now we have offices that are owned by massage therapy groups that have relegated chiropractors to the role of manual technicians. With medical physicians and physical therapists practicing chiropractic our world will shrink even more because of the short-sidedness of many of these doctors in our profession. Instead of elevating our profession many have chosen the lower road of mediocrity. Until, we evolve from a profession of mediocrity by utilizing proper procedures as well as producing continued research by our profession we will continue to lower the bar!

  • Russell, I appreciate your post. What I have found is that we have to educate our patients. Remember that a patient is in your office becuase they are looking for answers. You have to be a resource not only for your patients, the community, and the world for this profession to continue to grow.



  • Marco, I am fortunate to have worked with many medical professionals that do appreciate the work chiropractors perform. I am grateful for the relationship I have with my patients and continue to inform and educate, but it can be frustrating when we have those out there that lower the bar of chiropractic. When I do retire, I hope that I will have given to our profession.


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