Despite the rumors to the contrary, it is very clear that the treatment of Medicare beneficiaries and subsequent Medicare documentation requirements are not subluxation-based. How can one know this for sure? It is actually very easy. This fact is explained in all of the local coverage determinations (LCDs) for each region in the United States. All LCDs are based on Section 240 of the Medicare Benefit Policy Manual, which can be searched for by name and downloaded from the Internet as a PDF document. When you open the manual, the subtitle reads: Chapter 15 - Covered Medical and Other Health Services. Section 240 is devoted exclusively to chiropractic.
Prior to reading my LCD for Florida and Section 240, my impression was that the Medicare documentation was subluxation-based because that is what is often repeated. After reading these two documents, it becomes very clear that the treatment and documentation of Medicare patients is absolutely pain-based. As each LCD is slightly different, the information in this article comes directly from Section 240, which applies to all 50 states.
Section 240.1.3: Necessity for Treatment
Typical subluxation-based care is not based on pain or any other symptoms. Indeed, subluxation-based chiropractic is often described as non-therapeutic and even wellness care, a position that is in direct conflict with Medicare treatment and documentation requirements as outlined in Section 240 under the heading of Necessity for 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, as described above."
Significant neuromusculoskeletal conditions are painful and we must document that manipulation has a direct therapeutic relationship to this condition. The best way to view Medicare documentation is in the following manner: A 739 ICD-9 code cites the spinal level of dysfunction and the secondary diagnosis describes the significant neuromusculoskeletal condition. According to section 240, we do not even have to use the word subluxation in the patient record:
"Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named."
In other words, we can identify the level of dysfunction and use the acceptable terms provided by Medicare, such as "limited, lost, or restricted" motion, but do not have to specifically use the word subluxation. If what I have written so far seems contrary to what you have heard, please read section 240 and your LCD.
I Thought PART Was for Subluxation?
The PART documentation requirements are not unique to subluxation. Pain, asymmetry, range-of-motion issues, and tissue changes will be identifiable in any significant neuromusculoskeletal condition of the spine, which we must identify with the acceptable ICD-9 codes as outlined in our regional LCD. PART serves to confirm that a patient is suffering from a significant neuromusculoskeletal condition, which should be amenable to manipulation. So, while subluxation is in the LCDs and Section 240, the reimbursable treatment is for pain and related limited function, but not for "subluxation" in the common wellness and symptom-free context.
Pain-Based Documentation
- Pain-based history requirements are outlined in Section 240. We must include the following:
- Symptoms causing patient to seek treatment
- Mechanism of trauma
- Quality and character of symptoms/problem
- Onset, duration, intensity, frequency, location and radiation of symptoms
- Aggravating or relieving factors
Clearly, non-symptom, non-therapeutic, subluxation-based chiropractic is in conflict with Medicare treatment and documentation requirements. A patient's symptoms must be identified and we must document that the level to be manipulated is capable of producing the symptoms. From Section 240:
"These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined."
Notice that the only symptom mentioned is pain, which clearly demonstrates the pain-based focus of treating Medicare patients. Additionally, we should recall that the ICD-9 codes accepted by Medicare are related to painful neuromusculoskeletal conditions of the spine.
Pain-Based Examination
Read the last sentence from the above quote from Section 240. When you cite in the patient record the vertebra you plan to adjust, you must demonstrate causality of the subluxation by stating in the record that "the particular vertebra listed is capable of producing pain in the area determined." To be able to do this requires a knowledge of spinal pain patterns and the examination procedures that produce/reduce the pain, which is typically very easy to do in the clinical setting. The quickest way to become knowledgeable in this area is to read the following:
- Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord, 2007;8:75.
- Souza TA. Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms, 4th Edition. Boston: Jones & Bartlett; 2009. (Hint: focus on the spine pain and headache chapters.)
- Feinstein B, Langton JNK, Jameson RM, Schiller F. Experiments on pain referred from deep somatic tissues. J Bone Joint Surg, 1954;35A:981-87.
