To understand how coverage for chiropractic services works under Medicare and Medicaid, we first have to understand how chiropractors' role is defined with the Centers for Medicare & Medicaid Services (CMS). Chiropractic benefits were not originally part of Medicare/Medicaid legislation, and were only added in 1972. Unfortunately, due to the understanding of spinal conditions at the time among chiropractic and medical physicians alike, the language of the amendment severely limits the scope of chiropractors' reimbursement within Medicare/Medicaid.
According to a report published by Department of Health and Human Services - Office of Inspector General (2005), chiropractors are "physicians who are eligible for Medicare reimbursement", BUT:
Only for manual manipulation of the spine
It must be to treat a neuromusculoskeletal condition (nerve, joint, and/or muscle problem)
Manipulation must be previously established as an appropriate treatment for that condition
Treatment must be "medically necessary" (more on this below)
All of the above must be documented.
So what does that mean? In simple terms, in order for care provided by a chiropractic physician to be covered by Medicare/Medicaid, the chiropractor must establish "medical necessity". This means basically that there is a problem and that treatment for that problem is expected to result in meaningful permanent in that problem. In order to show these criteria are met, a thorough examination must be performed (which CMS will not pay for), and documentation must show findings that support the diagnosis and treatment plan.
"Wait, CMS doesn't cover the exam?"
Nope. In 1972, chiropractors had a very different approach to diagnosis and treatment. In many cases, exams were really just focused on finding where to adjust. 50 years later, the profession has evolved significantly, and most states recognize doctors of chiropractic as physicians who are trained and qualified to perform complete physical examinations, as well as order and interpret labs and imaging. Although chiropractic has modernized considerably, CMS is still operating on language written over 50 years in the past.
"What else is not covered under Medicare/Medicaid?"
Medicare does not cover any treatment or examination provided by a chiropractor other than spinal manipulation. Exercises, therapies such as e-stim or ultrasound, massage and manual therapy, and dry needling are all non-covered services. Imaging and laboratory testing are also not covered if ordered by a chiropractor.
Additionally, if a Medicare patient needs to be seen by a specialist which requires a referral, that referral must come from the patient's medical provider, not a chiropractor. Regardless of whether the referral is appropriate or necessary, CMS will not pay for any care resulting from that referral if it was initiated by a chiropractor.
"What if I have an extremity problem?"
Medicare does not cover any chiropractic care related to any extremity (hips, shoulders, knees, etc.), regardless of diagnosis or appropriateness of the treatment. This is one of the many reasons we wanted to bring Dr. Jesse Sampogna, PT DPT into our team of providers - so that we could continue to help our patients get appropriate care and still be covered by Medicare.
"Can you offer free/discounted prices for services not covered under Medicare?"
Many offices will give discounts or even simply not charge Medicare/Medicaid for services not covered by CMS. This is actually illegal and could result in severe consequences, as the federal government considers this "inducement", which is essentially bribing patients to get treatment so the provider can bill Medicare. At Price Chiropractic Center, if we believe a service not covered by CMS will be necessary or very beneficial to your recovery, we will always inform you of the cost up front to ensure there are no surprises on your bill.
If you have questions about your situation specifically, please do not hesitate to ask one of our providers or staff!
Reference:
Department of Health and Human Services - Office of Inspector General. (2005, June). CHIROPRACTIC SERVICES IN THE MEDICARE PROGRAM: PAYMENT VULNERABILITY ANALYSIS. https://oig.hhs.gov/oei/reports/oei-09-02-00530.pdf