A recent report issued by the Department of Health and Human Services (HHS) claims that the amount paid by the Medicare to chiropractors in 2013 for spinal manipulation was medically unnecessary. Reports indicate that approximately 82% (around $359 million) of the total $439 million Medicare reimbursement was for spinal manipulation.
According to the HHS Office of Inspector General (OIG), many unnecessary chiropractic services were provided to patients after more than 90 days of the initial treatment. These chiropractic services represented medical care but Medicare does not reimburse these treatment methods and defines them as medically unnecessary.
The estimates from ONG were based on a sample of 105 services, which were billed to the Medicare. However, the American Chiropractic Association responded to this report by saying that the profession has cleaned up their Medicare claims act since the year 2013.
Medicare’s coverage of chiropractic care to spinal manipulation corrected spinal subluxations, the ostensible source of impaired joint function and pain. However, Medicare has limited their coverage for that. CMS defines spinal subluxation as a “motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered, although contact between joint surfaces remains.” Nonetheless, in chiropractic circles, subluxation can be referred to spinal dysfunction, which is as opposed to an anatomic problem, visible on X-ray. Still, many experts in the medical field do not share this opinion.
Medicare actually pays for “active/corrective” chiropractic treatments of subluxation, which are demonstrated either through physical examination or on an X-ray. CMS has also stated that spinal adjustments or manipulations for acute conditions might require 3 months, but chronic problems might require more time and can exceed the 3-month period. In such a scenario, when further services available to a patient is not capable of improving his/her situation, then the services becomes supportive instead of being corrective. Hence, they fall under the maintenance care.
Chiropractors push maintenance care to prevent recurrence of treated spinal problems and even as a way to avoid spinal problems. The Journal of Manipulative and Physiological Therapeutics published a study in the year 2000, which claimed that maintenance care accounted for approximately 23 percent of chiropractic revenue.
The OIG report states that if chiropractors failed to add an Acute Treatment (AT) modifier while submitting their claims to Medicare for active/corrective treatment of subluxation, then the claim will be denied.