Concerned About Medicare Billing? Let Pain and Subluxation Set You Free

The title of this article may seem odd at first, second and even further glances. It will make more sense if you can separate yourself from whatever emotion you may have regarding the topics of pain and subluxation.

Several years ago, I was involved in a Medicare compliance project. Prior to that experience, the nature of Medicare documentation was quite confusing to me. I would sit in on required CE classes and usually be confused with how Medicare documentation requirements were presented. This confusion cleared up after I was invited to participate in the above-mentioned compliance project.

The group working on the project found themselves stuck because they realized Medicare requires DCs to list the specific vertebral level responsible for generating the painful symptoms, which they did not adequately understand. Since I am supposedly a "pain" guy, I was invited to assist.

I was forwarded the Medicare Benefit Policy Manual (Chapter 15) and Local Coverage Determination (LCD) for Florida and began to investigate. Each document is a short read and they are mostly identical. I quickly discovered Medicare speaks to a different type of subluxation than most of us were taught in school; this is because Medicare's subluxation is specifically about pain generation.

It is not difficult to imagine that for a subluxation-based DC, viewing subluxation from the perspective of pain would be contrary to their model of subluxation, because subluxation is viewed to be about subluxation, not pain. This difficulty can also exist for DCs who utilize motion palpation for spinal analysis. Interestingly, one can be a straight or non-straight chiropractor and equally embrace motion palpation, but each may view the procedure differently regarding the nature of subluxation.

During the Medicare project, I interacted with a DC who did not consider himself to be a straight chiropractor and used motion palpation. He found a fixation at C1-C2 and the patient had cervicothoracic pain. He found no fixations in the area of pain expression; did not cite in the medical record the specific vertebra capable of generating the symptoms; and did not in any other way explain the symptoms were vertebrogenic.

This lack of documenting the causal relationship of the spine to the patient's pain presentation is in conflict with Medicare documentation requirements. Here is the direct quote from the Medicare Benefit Policy Manual, which is universally applied in all LCDs:

"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."

I am not suggesting upper cervical dysfunction cannot contribute to cervicothoracic pain; however, Medicare requires us to describe the patient's pain pattern in the medical record and indicate whether the vertebra to be adjusted is causing the pain. Notice that I italicized medical record because from the perspective of Medicare, patient records are medical records, not chiropractic records.

The reason for the requirement to record the vertebra-pain relationship is because nonmusculoskeletal tissues can also generate spinal pain. For example, low back pain is a common symptom in the rare individual who develops bacterial endocarditis. This patient needs antibiotics, not spinal manipulation.

Other examples are patients with back pain caused by an abdominal aortic aneurysms or prostate disease who need medical intervention, not spinal manipulation. Medicare only pays DCs for treating spine pain coming from the spine; thus, the requirement to document that the intended vertebra to be adjusted is indeed the pain generator.

If you can embrace the fact that from the perspective of Medicare, subluxation is about documenting pain and disability, then you will stress less when it comes to billing Medicare. And while it is not properly appreciated, Medicare actually wants to pay us for treating its beneficiaries (patients). The issue is that Medicare wants to make sure the patient's pain is coming from the spine, rather than a visceral tissue.