**Abstract:**  
  
Chiropractic manipulative treatment (CMT) is a form of manual treatment to
influence joint and neurophysiological function. This treatment may be
accomplished using a variety of techniques. Medicare covers limited
chiropractic services when performed by a chiropractor who is licensed or
legally authorized to furnish chiropractic services by the State or
jurisdiction in which the services are furnished (CMS Publication 100-01,
Medicare General Information, Eligibility and Entitlement Manual, Chapter 5,
Section 70.6). A chiropractor must also meet uniform minimum standards as set
forth in the CMS Internet-Only Manual (IOM) Publication 100-1, Chapter 5,
Section 70.6. This policy restates language directly from the CMS Internet-
Only manuals and if necessary provides clarification to educate providers on
specified Medicare requirements for the diagnosis, treatment, documentation
and billing of chiropractic services.  
**Indications  
  
Chiropractic Services - Active Treatment:**  
  
_The patient must have a significant health problem in the form of a
neuromusculoskeletal condition necessitating treatment, and 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._ (CMS Publication 100-02, _Medicare Benefit Policy
Manual_ , Chapter 15, Section 240.1.3)  
  
_Most spinal joint problems fall into the following categories:  
  
Acute subluxation - A patient's condition is considered acute when the patient
is being treated for a new injury, identified by x-ray or physical exam as
specified above. The result of chiropractic manipulation is expected to be an
improvement in, or arrest of progression, of the patient's condition.  
  
Chronic subluxation - A patient's condition is considered chronic when it is
not expected to significantly improve or be resolved with further treatment
(as is the case with an acute condition), but where the continued therapy can
be expected to result in some functional improvement. Once the clinical status
has remained stable for a given condition, without expectation of additional
objective clinical improvements, further manipulative treatment is considered
maintenance therapy and is not covered._ (CMS Publication 100-02, _Medicare
Benefit Policy Manual_ , Chapter 15, Section 240.1.3)  
  
An acute exacerbation is a temporary but marked deterioration of the patient's
condition that is causing significant interference with activities of daily
living due to an acute flare-up of the previously treated condition. The
patient's clinical record must specify the date of occurrence, nature of the
onset, or other pertinent factors that would support the medical necessity of
treatment. As with an acute injury, treatment should result in improvement or
arrest of the deterioration within a reasonable period of time.  
  
 _A. Maintenance Therapy  
  
Maintenance therapy includes services that seek to prevent disease, promote
health and prolong and enhance the quality of life, or maintain or prevent
deterioration of a chronic condition. When further clinical improvement cannot
reasonably be expected from continuous ongoing care, and the chiropractic
treatment becomes supportive rather than corrective in nature, the treatment
is then considered maintenance therapy._ (CMS Publication 100-02, _Medicare
Benefit Policy Manual_ , Chapter 15, Section 240.1.3A)  
  
 _B. 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._ (CMS Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter
15, Section 240.1.3B)  
  
 _ _The following are relative contraindications to Dynamic thrust:  
  
__

Articular hyper 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.

(CMS Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 15,
Section240.1.3B) _ _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 manipulations, vertebrobasilar insufficiency syndrome; and



A significant major artery aneurysm near the proposed manipulation.

(CMS Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 15,
Section 240.1.3B) **  
Limitations**  
  
 _The term "physician" under Part B includes a chiropractor who meets the
specified qualifying requirements set forth in 30.5 but only for treatment by
means of manual manipulation of the spine to correct a subluxation. _ (CMS
Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section
240)  
  
 _Coverage extends only to treatment by means of manual manipulation of the
spine to correct a subluxation provided such treatment is legal in the State
where performed. All other services furnished or ordered by chiropractors are
not covered._ (CMS Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15, Section 30.5)  
  
_Coverage of chiropractic service is specifically limited to treatment by
means of manual manipulation, i.e., by use of the hands. Additionally, manual
devices (i.e., those that are hand-held with the thrust of the force of the
device being controlled manually) may be used by chiropractors in performing
manual manipulation of the spine. However, no additional payment is available
for use of the device, nor does Medicare recognize an extra charge for the
device itself._ (CMS Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15: Section 240.1.3)  
  
_No other diagnostic or therapeutic service furnished by a chiropractor or
under the chiropractor 's order is covered. This means that if a chiropractor
orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray
or other diagnostic test, can be used for claims processing purposes, but
Medicare coverage and payment are not available for those services. This
prohibition does not affect the coverage of x-rays or other diagnostic tests
furnished by other practitioners under the program. For example, an x-ray or
any diagnostic test taken for the purpose of determining or demonstrating the
existence of a subluxation of the spine is a diagnostic x-ray test covered
under 1861(s)(3) of the Act if ordered, taken, and interpreted by a physician
who is a doctor of medicine or osteopathy. _ (CMS Publication 100-02,
_Medicare Benefit Policy Manual_ , Chapter 15, Section 240.1.1)  
  
The mere statement or diagnosis of "pain" is not sufficient to support medical
necessity for the treatments. The precise level(s) of the subluxation(s) must
be specified by the chiropractor to substantiate a claim for manipulation of
each spinal region(s). There are five spinal regions addressed by this LCD:
cervical region (atlanto-occipital joint), thoracic region
(costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-
iliac joint) and sacral region (ref. CPT Professional Edition 2017 p. 672).  
  
Medicare does not cover chiropractic treatments to extraspinal regions (CPT
98943).The five extraspinal regions are: head (including temporomandibular
joint, excluding atlanto-occipital) region; lower extremities; upper
extremities; rib care (excluding costotransverse and costovertebral joints)
and abdomen (CPT Assistant Nov 98:38).  
The five extraspinal regions referred to are: head (including,
temporomandibular joint, excluding atlanto-occipital) region; lower
extremities; upper extremities; rib cage (excluding costotransverse and
costovertebral joints) and abdomen (CPT Assistant Nov 98:38). Medicare does
not cover chiropractic treatments to extraspinal regions (CPT 98943), which
includes the head, upper and lower extremities, rib cage and abdomen.  
  
 _For Medicare purposes, a chiropractor must place an AT modifier on a claim
when providing active/corrective treatment to treat acute or chronic
subluxation. However the presence of the AT modifier may not in all instances
indicate that the service is reasonable and necessary. As always, contractors
may deny if appropriate after medical review._ (CMS Publication 100-02,
_Medicare Benefit Policy Manual_ , Chapter 15, Section 240.1.3) Modifier AT
must only be used when the chiropractic manipulation is "reasonable and
necessary" as defined by national policy and the LCD. Modifier AT must not be
used when maintenance therapy has been performed. The need for a prolonged
course of treatment should be appropriate to the reported procedure code(s)
and medical necessity must be documented clearly in the medical record.