CMS Scraps Chiropractor Exception
As of Jan. 1, 2008, radiologists can no longer order x-rays for Medicare patients referred to them by chiropractors in a non-hospital setting. The 2008 Medicare Fee Schedule Final Rule eliminated the “chiropractor exception,” which allowed non-treating physicians like radiologists to order diagnostic tests to identify a subluxation of the spine at the request of a chiropractor.
Before Jan. 1, 2000, the law required that an x-ray confirm the subluxation diagnosis for Medicare to reimburse for chiropractic adjustments to correct subluxations. Radiologists, though, do not qualify under Medicare rules as treating physicians who can order x-rays, and Medicare similarly restricts chiropractors from ordering x-rays. Therefore, the regulations provided a “chiropractor” exception. Then, in 2000, the law eliminated the requirement for x-ray confirmation of spinal subluxations, however, the exception remained in Medicare rules for eight years. Now, CMS has acted to align its reimbursement policies with the 2000 statutory change. Consequently, CMS no longer pays for x-rays or other diagnostic tests ordered by a non-treating physician to be used by chiropractors to demonstrate the subluxation.
The American Chiropractic Association (ACA) opposed the proposed rule to eliminate the chiropractor exception. The ACA argued that x-rays are essential to the chiropractic treatment plan of Medicare patients. Furthermore, the ACA pointed out that allowing chiropractors to refer patients to radiologists does not impose any clinical harm to patients; on contrary, it helps to curb health care spending by enabling patients to avoid additional trips to their primary care provider.
CMS disagreed, observing that other commenters noted that x-rays are not needed to identify spinal subluxations. Instead, the commenters stated that they use x-rays to rule out other conditions where manual manipulation of the spine is contraindicated or where more imaging studies are indicated. CMS decided that this use fell outside the chiropractic exception.
CMS is currently evaluating the chiropractic services demonstration project that began on April 1, 2005, and ended on March 31, 2007. This demonstration project allowed chiropractors to provide services that were approved by CMS including ordering diagnostic tests and therapies in Maine, New Mexico, Illinois, Iowa, and Virginia.
The ACR will follow up with the analysis of the chiropractic services demonstration project as soon as CMS makes it available.
Attachment: 42 CFR Ch. IV, 410.32 (a) (1) (10-1-04 Edition)