Chiropractic Services

LCD Information Document Information Source LCD ID N/A LCD ID L37387 Original ICD-9 LCD ID Not Applicable LCD Title Chiropractic Services Proposed LCD in Comment Period N/A Source Proposed LCD DL37387 Opens in a new window Original Effective Date For services performed on or after 09/25/2017 Revision Effective Date For services performed on or after 12/19/2024 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 08/10/2017 Notice Period End Date 09/24/2017 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 Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member42 CFR §410.32(a) 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 Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §240 Chiropractor’s Services-General Coverage Indications, Limitations, and/or Medical Necessity 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 carried out by a chiropractor who is legally authorized or licensed to provide chiropractic services by the State or jurisdiction in which the services are provided. A chiropractor must also meet uniform minimum standards as set forth in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (IOM). This policy restates language directly from the CMS IOMs 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.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. An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is causing significant interference with activities of daily living (ADLs) 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 attempt to avert disease, facilitate health and extend and improve the quality of life; or therapy that is implemented to preserve or avoid deterioration of a chronic condition. The treatment is considered maintenance therapy when additional clinical advancement cannot logically be expected from constant ongoing care and the chiropractic treatment becomes auxiliary rather than curative in nature.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. The following are relative contraindications to dynamic thrust: Articular hypermobility 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. 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. Limitations: 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. 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 Social Security Act if ordered, taken and interpreted by a physician who is a doctor of medicine or osteopathy. The specified qualifying requirements for the term "physician", which includes a chiropractor, and the coverage extensions to treat by means of manual manipulation of the spine to correct a subluxation are set forth in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §30.5 Physician Services-Chiropractor's Services.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 5 spinal regions addressed by this local coverage determination (LCD): cervical region (atlanto-occipital joint), thoracic region (costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region.Medicare does not cover chiropractic treatments to extraspinal regions. The 5 extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region, lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral joints) and abdomen. The need for a prolonged course of treatment should be appropriate to medical necessity and must be documented clearly in the medical record. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

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 carried out by a chiropractor who is legally authorized or licensed to provide chiropractic services by the State or jurisdiction in which the services are provided. A chiropractor must also meet uniform minimum standards as set forth in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (IOM). This policy restates language directly from the CMS IOMs 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. 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. An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is causing significant interference with activities of daily living (ADLs) 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 attempt to avert disease, facilitate health and extend and improve the quality of life; or therapy that is implemented to preserve or avoid deterioration of a chronic condition. The treatment is considered maintenance therapy when additional clinical advancement cannot logically be expected from constant ongoing care and the chiropractic treatment becomes auxiliary rather than curative in nature. 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. The following are relative contraindications to dynamic thrust: Articular hypermobility 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. 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. Limitations: 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. 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 Social Security Act if ordered, taken and interpreted by a physician who is a doctor of medicine or osteopathy. The specified qualifying requirements for the term "physician", which includes a chiropractor, and the coverage extensions to treat by means of manual manipulation of the spine to correct a subluxation are set forth in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §30.5 Physician Services-Chiropractor's Services. 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 5 spinal regions addressed by this local coverage determination (LCD): cervical region (atlanto-occipital joint), thoracic region (costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region. Medicare does not cover chiropractic treatments to extraspinal regions. The 5 extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region, lower extremities, upper extremities, rib cage (excluding costotransverse and costovertebral joints) and abdomen. The need for a prolonged course of treatment should be appropriate to medical necessity and must be documented clearly in the medical record.