Chiropractic Services

LCD Information Document Information Source LCD ID N/A LCD ID L37254 Original ICD-9 LCD ID Not Applicable LCD Title Chiropractic Services Proposed LCD in Comment Period N/A Source Proposed LCD DL37254 Opens in a new window Original Effective Date For services performed on or after 11/06/2017 Revision Effective Date For services performed on or after 01/29/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 09/21/2017 Notice Period End Date 11/05/2017 CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA): Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Code of Federal Regulations:42 CFR 410.21 describes limitations on services of a chiropractor.42 CFR Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements). CMS Publications:CMS Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5: 70.6 Chiropractors CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: 30.5 Physician Services – Chiropractor’s Services CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: 240 Chiropractic Services - General Coverage Indications, Limitations, and/or Medical Necessity 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. IndicationsChiropractic 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 TherapyMaintenance 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. ContraindicationsDynamic 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. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A