The Endless Medicare Saga
A Chiro.Org article collection
First, you might want to catch up on the history (pre 2006) of our professional struggles with Medicare to gain fair coverage for our patients, and to level the playing field with all the other “covered” providers.

Medicare Documentation Guidelines
The American Chiropractic Association
The American Chiropractic Association provides this commentary in order to assist its members to better understand the Medicare PART clinical documentation guidelines. These are Centers for Medicare and Medicaid Services (CMS) guidelines that apply to Medicare only.   However, since these guidelines describe “medical necessity” to Medicare, they should also apply to any other insurer's requirements.

Best Practices for Chiropractic Care for Older Adults: A Systematic Review
and Consensus Update
J Manipulative Physiol Ther. 2017 (Mar 14) [Epub] ~ FULL TEXT
A total of 199 articles were found; after exclusion criteria were applied, 6 articles about effectiveness or efficacy and 6 on safety were added. The Delphi process was conducted from April to June 2016. Of the 37 Delphi panelists, 31 were DCs and 6 were other health care professionals. Three Delphi rounds were conducted to reach consensus on all 45 statements. As a result, statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only.
This is an update of the 2010 Consensus Document titled:
Recommendations for Chiropractic Care for Older Adults: Results of a Consensus Process

Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic
and Opioid Use in Younger Medicare Beneficiaries
J Manipulative Physiol Ther. 2016 (May);   39 (4):   263–266 ~ FULL TEXT
In this exploratory analysis, we found a strong inverse correlation between the per-capita supply of DCs and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Further, we found a strong inverse correlation between the per-capita spending on CMT and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Based upon our findings, we suggest that Medicare consider promoting a trial of CMT prior to use of conventional medical care for patients with neck or back pain. The rationale for use of CMT prior to medical care is that concurrent medical care might result in opioid prescriptions; however, further study that examines opioid use when CMT and conventional medical care are concurrently provided is warranted.

The Association Between Use of Chiropractic Care and Costs of Care
Among Older Medicare Patients With Chronic Low Back Pain
and Multiple Comorbidities
J Manipulative Physiol Ther. 2016 (Feb);   39 (2):   63–75 ~ FULL TEXT
After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided.

Regional Supply of Chiropractic Care and Visits to Primary Care
Physicians for Back and Neck Pain
J Am Board Fam Med. 2015 (Jul);   28 (4):   481–490 ~ FULL TEXT
Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11–14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services.

Chiropractic Care and the Risk of Vertebrobasilar Stroke:
Results of a Case-control Study in U.S. Commercial and
Medicare Advantage Populations
Chiropractic & Manual Therapies 2015 (Jun 16);   23:   19 ~ FULL TEXT
We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.

Deconstructing Chronic Low Back Pain in the Older Adult -
Shifting the Paradigm from the Spine to the Person
Pain Medicine 2015 (May);   16 (5):   881–885 ~ FULL TEXT
Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled [1], and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket. [1–3]   Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected.

Risk of Stroke After Chiropractic Spinal Manipulation in Medicare B
Beneficiaries Aged 66 to 99 Years With Neck Pain
J Manipulative Physiol Ther. 2015 (Feb);   38 (2):  93–101 ~ FULL TEXT
The proportion of subjects with stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33–0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01–1.19).   Among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.

Risk of Traumatic Injury Associated with Chiropractic Spinal
Manipulation in Medicare Part B Beneficiaries Aged 66–99
Spine (Phila Pa 1976) 2015 (Feb 15); 40 (4): 264–270
Among Medicare beneficiaries aged 66–99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.

Perceived Value of Spinal Manipulative Therapy and Exercise Among Seniors
With Chronic Neck Pain: A Mixed Methods Study
J Rehabil Med. 2014 (Nov);   46 (10):   1022–1028 ~ FULL TEXT
Participants placed high value on their relationships with health care team members, supervision, individualized care, and the exercises and information provided as treatment. Change in symptoms did not figure as prominently as social and process-related themes. Percpetions of age, activities, and co-morbities influenced some seniors' expectations of treatment results, and comorbidities impacted perceptions of their ability to participate in active care.   Relationship dynamics should be leveraged in clinical encounters to enhance patient satisfaction and perceived value of care.

Chiropractic Use in the Medicare Population: Prevalence, Patterns,
and Associations With 1-Year Changes in Health and Satisfaction With Care
J Manipulative Physiol Ther. 2014 (Oct);   37 (8):   542–551 ~ FULL TEXT
This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

Short Term Treatment Versus Long Term Management of Neck and Back
Disability in Older Adults Utilizing Spinal Manipulative Therapy and
Supervised Exercise: A Parallel-group Randomized Clinical Trial
Evaluating Relative Effectiveness and Harms
Chiropractic & Manual Therapies 2014 (May 23);   22:   21 ~ FULL TEXT
This is one of the first full-scale randomized clinical trials to compare short term treatment and long term management using SMT and exercise to treat spine-related disability in older adults. It builds on previous research by the investigative team showing improvement with three months of SMT and exercise in similar populations, which regressed to baseline values in long term follow up without further intervention 88. As back and neck pain in older adults are often chronic and among several co-morbidities [6, 8], we theorized that long term management may result in sustained improvement compared to short term treatment. Identifying the most favorable duration of treatment is a pragmatic question common to patients, clinicians, policy makers, and third-party payers alike. [25, 89] This is especially important to address in an older population, whose long term functional ability is essential to maintaining vitality and independence.

The Comparative Effect of Episodes of Chiropractic
and Medical Treatment on the Health of Older Adults
J Manipulative Physiol Ther 2014 (Mar);   37 (3):   143–154 ~ FULL TEXT
This study provides evidence of the comparative effectiveness of chiropractic care relative to medical-only services on the functional health of older adults during acute episodes of back care. Our results are the first to show the importance of examining chiropractic use within an episode of care in traditional practice settings, rather than focusing on visit frequency alone. Moreover, we evaluated the effects of the treatments received during the episodes on ADLs, IADLs, and LBFs, which are critically important measures that inform patients, clinicians, and payers about the benefits and harms of certain treatments relative to others. Given the literature supporting a minimally effective chiropractic treatment level for back problems, this research provides additional support that such therapeutic levels are indeed beneficial in terms of protecting older persons from functional declines and self-rated health over as much as 2 years.

Epidural Steroid Injections:
Are long-term Risks Worth Short Term Benefits?
ACA News ~ February 2014
While it is true that epidural steroid injections (ESI) are not FDA approved, Medicare, Medicaid, workers’ compensation and most other insurers continue to pay hundreds of millions of dollars per year for this controversial procedure.   Ironically, on every vial of Kenalog (a popular steroid used for epidural injections) there is actually a warning against its use for epidural injections, yet proceduralists continue to use it.

Our No. 1 Medicare Documentation Error
Dynamic Chiropractic ~ January 15, 2014
We have all heard that chiropractic documentation is being reviewed by multiple Medicare contractors and that we are failing these reviews miserably. So, where are we going wrong? In this and subsequent articles, let's address the top reasons we are failing review, starting with the No. 1 reason – our treatment plan documentation.

Chiropractic Use and Changes in Health Among Older Medicare Beneficiaries:
A Comparative Effectiveness Observational Study
J Manipulative Physiol Ther 2013 (Nov);   36 (9):   572–584
The evidence in this study suggests that chiropractic treatment has comparable effects on functional outcomes when compared with medical treatment for all Medicare beneficiaries, but increased risk for declines in self-rated health among beneficiaries with back conditions.

Trends in the Use and Cost of Chiropractic
Spinal Manipulation Under Medicare Part B
Spine J. 2013 (Nov);   13 (11):   1449–1454
The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.

Straight Chiropractic Philosophy As A Barrier To Medicare Compliance:
A Discussion of 5 Incongruent Issues
Journal of Chiropractic Humanities 2013 (Oct 24);   20 (1):   19–26
The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.

Beyond Spinal Manipulation: Should Medicare Expand Coverage
for Chiropractic Services? A Review and Commentary on the
Challenges for Policy Makers
Journal of Chiropractic Humanities 2013 (Aug 28);   20 (1):   9–18
The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.

Cross-Referencing Regions of Complaint, PART Findings,
Diagnoses and CPT Codes
Dynamic Chiropractic ~ June 15, 2013
In 2012 the Centers for Medicare and Medicaid Services and CMS-contracted reviewers performed chiropractic Medicare reviews nationwide. The results of their efforts were not good news for the chiropractic profession. Volumes have already been written about this concern. Here, I offer a set of questions to help guide doctors in documenting the number of patient complaints, subluxations, diagnoses, regions adjusted and the appropriate billing codes. This series of questions is accompanied by comments and tables to clarify the importance of each question.

The Medicare Hurdle That Continues to Block
Our Professional Progress
Dynamic Chiropractic ~ April 9, 2012
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.

Chiropractic Episodes and the Co-occurrence of Chiropractic and
Health Services Use Among Older Medicare Beneficiaries
J Manipulative Physiol Ther 2012 (Mar);   35 (3):   168–175 ~ FULL TEXT
Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

The Role of Chiropractic Care in Older Adults
Chiropractic & Manual Therapies 2012 (Feb 21);   20 (1):   3 ~ FULL TEXT
While there is already substantial published research to assist the evidence-based DC in his/her care plan for the older adult, there is a need for well designed clinical trials and large observational studies to identify the most beneficial treatments, particularly for complementary and alternative interventions such as manual therapy including, but not limited to, spinal manipulative therapy and acupuncture.

A Longitudinal Study of Chiropractic Use Among Older Adults
in the United States
Chiropractic & Osteopathy 2010 (Dec 21);   18:   34 ~ FULL TEXT
There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".

Best Practices Recommendations for Chiropractic Care for Older Adults:
Results of a Consensus Process
J Manipulative Physiol Ther 2010 (Jul);   33 (6):   464–473 ~ FULL TEXT
A multidisciplinary panel of experienced chiropractors was able to reach a high level (80%) of consensus on evidence-informed best practices for the chiropractic approach to evaluation, management, and manual treatment for older adult patients.
These recommendations have been updated by the 2017 article:
Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update

Trends, Major Medical Complications, and Charges Associated with Surgery
for Lumbar Spinal Stenosis in Older Adults
JAMA. 2010 (Apr 7);   303 (13):   1259–1265 ~ FULL TEXT
There is a lack of evidence-based support for the efficacy of complex fusion surgeries over conservative surgical decompression for elderly stenosis patients. There is, however, a significant financial incentive to both hospitals and surgeons to perform the complex fusions. Spinal stenosis is the most frequent cause for spinal surgery in the elderly. There has been a slight decrease in these surgeries between 2002 and 2007. However, there has also been an overall 15 fold increase in the more complex spinal fusions (360 degree spine fusions).

Correctly Completing a Medicare Claim
Dynamic Chiropractic ~ June 3, 2009
This article takes a step-by-step analysis on what goes in each box on the HCFA form, and reviews the proper use of modifiers.

American Chiropractic Association Responds to the May 2009 OIG Report
ACA News ~ June 10, 2009
In a response released today, the American Chiropractic Association (ACA) refuted the findings and recommendations outlined in a May 2009 report released by the Department of Health and Human Services Office of the Inspector General (OIG), noting the methods used by the OIG may have resulted in an overestimate of inappropriate claims. In commenting on the report, ACA said the OIG’s decision to restrict data collection to only those episodes of chiropractic care resulting in claims of more than 12 visits by the same doctor, likely skewed the data pool by focusing on a subpopulation previously identified to be more problematic. As a point of comparison, an OIG report released in 2005 investigated data collected from a global sample of claims.
Review OIG's 2009 Full Report or the 2005 Full Report now.

Patients in Medicare Demonstration Project
Give Their Chiropractors High Marks
ACA News ~ January 26, 2010
According to long-awaited results from a congressionally mandated pilot project testing the feasibility of expanding chiropractic services in the Medicare program, patients have a high rate of satisfaction with the care they receive from doctors of chiropractic. When asked to rate their satisfaction on a 10-point scale, 87 percent of patients in the study gave their doctor of chiropractic a level of 8 or higher. What’s more, 56 percent of those patients rated their chiropractor with a perfect 10.

Chiropractic and Exercise for Seniors With Low Back Pain or Neck Pain:
The Design of Two Randomized Clinical Trials   NCT00269308   and   NCT00269321
BMC Musculoskelet Disord. 2007 (Sep 18);   8:   94 ~ FULL TEXT
To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers. This article presents the rationale and design of two mixed methods clinical trials, each consisting of an RCT, with cost-effectiveness and qualitative studies conducted alongside the central trial. Both are anticipated to be completed in 2007, at which time the results will be made available.

Medicare Do's and Don'ts
A step-by-step approach to use of modifiers, and HCFA requirements. This 2 page Acrobat document (93 KB) covers all the most recent information updates amd recommendations. Thanks to the ACA and Susan McClelland for preparing these materials!

President Bush Signs Legislation Reversing Medicare Physician Fee Cuts
Arlington, Va. – Feb. 8, 2006   President Bush has signed legislation that not only reverses the current 4.4 percent Medicare physician payment reduction, which went into effect on the first of year, but will also provide automatic reprocessing of claims retroactive to Jan. 1, 2006. The legislation was included in the Deficit Reduction Act.