Noridian Policy Illustrates Ongoing Medicare Challenges for Chiropractic

On Nov. 9, 2010, Noridian Administrative Services, LLC, posted a notice on its Web site titled, "Chiropractic Services Using Computer Analysis and Piezoelectric Sensors." Noridian is the Medicare administrative contractor for Alaska, Arizona, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming. In its Medicare Part B update three days later, Noridian informed everyone of these changes to its local coverage determination. The changes Noridian announced related to two areas: examination and treatment.

Quoting from the posted change, the examination section stated: "Does not meet chiropractic benefit criteria: Examination by computer analysis or any other diagnostic tools such as Neurocalometer, Paraspinal Electromyography, Spinoscopy, Thermography." The changes to the treatment section stated: "Do not meet chiropractic coverage criteria: Treatment by any other means, such as Piezoelectric sensor (Pro-Adjuster, PulstarFRAS), any other electric device."

When I received the notification from Noridian, I contacted Christian Evans, president of Sense Technology, Inc., the maker of the PulstarFRAS adjusting instrument. After discussing the implications, we agreed that Noridian's decision posed a significant threat to the chiropractic profession by limiting a doctor's ability to exercise their clinical judgment in determining what is best for the patient. Christian had his legal team contact Noridian to discuss this policy decision.

On Nov. 22, Noridian issued a modified statement omitting the names of specific instruments, restating national policy and including the statement: "Note: Examination by computer analysis or any other diagnostic tools does not meet chiropractic benefit criteria." While this is a reiteration of existing policy, it still restricts chiropractors in their ability to use their clinical judgment to apply the diagnostic tools they find most beneficial and accurate.

If the original policy had stood, every chiropractor in nine states (nearly 20 percent of the country) utilizing any form of electronically assisted adjusting would have been unable to bill Medicare for their adjustments. Since the only chiropractic service paid by Medicare is the adjustment, these doctors and their patients would have been completely shut out of the Medicare system.

The Medicare Benefit Policy Manual states that subluxations must be proven by either X-ray or PART examination. Quoting from the manual:

"An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary's health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated."

According to the policy manual, P.A.R.T. consists of the following: "P = Pain/tenderness evaluated in terms of location, quality, and intensity; A = Asymmetry/misalignment identified on a sectional or segmental level; R = Range-of-motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and T = Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle and ligament. To demonstrate a subluxation based on physical examination, two of the four criteria mentioned above are required, one of which must be asymmetry/misalignment or range-of-motion abnormality."

The incident with Noridian illustrates one of the problems we have with Medicare: The national policies are very broad and subject to interpretation by the individual carriers. Medicare is more aggressively enforcing policy and the "fluid" nature of some of the policies regarding chiropractic make it very hard for chiropractors to comply.

By way of example, I had occasion to work with a doctor who was under review by Noridian. The reviewer insisted that the doctor perform orthopedic and neurological exams at every visit. The medical equivalent would be to have the patient call the doctor after taking each individual pill in a course of antibiotic therapy. In other words, the reviewer was insisting on a policy of unreasonable over-examination.

When you combine examples like this (which are numerous) with the following facts, you can see that we have serious problem with Medicare and that individual doctors, and the profession as a whole, face some serious challenges with Medicare in the coming months and years:

• Chiropractic has historically had one of the highest CERT error rates of all provider types since the first CERT report in 2003.
• Chiropractic is under Special Study Review by CMS due to our high error rate. The first report from that review is due out in March of 2011 and indications now are that we will have a 90%+ error rate in that report.
• The Office of Inspector General has been issuing reports for the past 25 years that paint chiropractic in a bad light and seek to limit us to 12 visits per year.
• CMS is about to implement new Medicare enrollment requirements including screenings and mandatory office compliance programs. With our historically high error rate, it is expected that chiropractic will be the first to feel the full effects of these changes.

Extraordinary challenges such as these require extraordinary efforts. No longer will business as usual ensure that chiropractic will maintain its rightful place as a health care choice. The ideal situation, in my opinion, would be for the ACA and the ICA to form a joint Medicare committee exclusively populated by doctors qualified to address compliance, coding, billing and documentation issues. Such a joint committee would go a long way to ensure our patients continue to have chiropractic as an option.