Since 1973, Medicare has covered manual manipulation of the spine for the treatment of certain neuromusculoskeletal conditions. To get paid, chiropractors are supposed to (a) specify the region of the spine where the supposed problem exists, (b) diagnose a medically recognized condition that is related to that spinal region, (c) document symptoms, physical findings, and/or x-ray findings that are related to that region, and (d) record a treatment plan that specifies goals and objective measures to evaluate treatment effectiveness. The chiropractor must also attest that the patient is receiving “active” treatment, which is defined as a “reasonable expectation of recovery or improvement of function.” Services intended to prevent disease, promote health, prolong or enhance the quality of life, or maintain or prevent deterioration of a chronic condition are considered “maintenance care” and are not covered.
To bill for their services, chiropractors must use one of three Current Procedural Terminology (CPT) codes:
- 98940 (for manipulation of 1 or 2 two regions)
- 98941 (for manipulation of 3 or 4 regions)
- 98942 (for manipulation of 5 regions)
The Five Regions of the Spine
Most people who might benefit from spinal manipulation are patients with acute low back pain or neck pain. Such problems seldom require more than a few sessions in which manipulation is applied to one or possibly two regions of the spine. Patients with chronic back or neck pain who might benefit from spinal manipulation might need more, but active treatment seldom requires more than 12 sessions and rarely requires more than 24. Chiropractors are notorious for urging patients who recover from acute pain to keep coming for “corrective” and “wellness” care. The percentage who routinely do this is unknown but not small.
To increase Medicare payments, many chiropractors manipulate more regions than necessary, treat more frequently than needed, and/or report treating more regions than actually treated. Some also try to conceal the fact that they are providing maintenance therapy by changing their diagnosis every 12 visits.
Very few conditions require treatment of more than two spinal regions. For example, people with low-back pain are unlikely to neck manipulation; and people with neck pain are unlikely to need low-back manipulation. Thus, most claims for 3- or 4-region manipulation are questionable and all claims for 5-region manipulation should be highly suspect.
ProPublica has published a handy database of Medicare payments made to practitioners in 2014. The top billers in the United States for CPT codes 98942, 98941, and 98940 can be displayed, and from there it it possible to identify the top billers in each state, see the average number of visits per patients, and pick out hundreds who very likely billed for more services than necessary. Data for 2012 through 2015 are available on the Centers for Medicare & Medicaid Services (CMS) Web site, but the interface is not user-friendly and expert knowledge would be necessary to harvest the data for statistical study.
I believe that it would be simple to ban payments for CPT code 98942 and to implement pre-payment screening of claims from chiropractors who bill all or nearly all of their visits with 98941 or 98942. However, no such measures appear to be under consideration. I did find a case where the State of Washington’s chiropractic licensing commission disciplined a chiropractor who used code 98942 to bill insurance companies repeatedly for services rendered to 12 patients. The board concluded that the chiropractor (Edward L. West, D.C.) had failed to document performance of these treatments and disciplined him for inadequate record-keeping. The agreed order that settled this case required West to pay a $5,000 administrative fine and take 24 hours of continuing education in the areas of coding and record-keeping. It would be interesting to know what caused the commission to examine West’s records, whether he performed 5-region manipulations, and, if so, whether he could have justified their use. State licensing boards could easily reduce billings for code 98942, but I doubt that they will ever do so.
The OIG Reports
Since 1986, the Office of the Inspector General has issued at least 17 reports that expressed concrn about inappropriate payments to chiropractors:
- Medicare Needs Better Controls to Prevent Fraud, Waste, and Abuse Related to Chiropractic Services (2018) —Notes that Medicare continued to make hundreds of millions in improper payments each year and suggested establishing a threshold for the number of chiropractic services beyond which medical review would be required for additional services.
- A Brooklyn Chiropractor Received Unallowable Medicare Payments for Chiropractic Services (2017)—Explains how an audit concluded that a chiropractic clinic in Michigan received least $672,805 over 2 years for services that were not allowable in accordance with Medicare requirements
- Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply with Medicare Requirements (2016) — Estimated that in 2013, $359 million (82%) of $438 million paid to chiropractors under Medicare Part B did not comply with Medicare requirements
- A Michigan Chiropractor Received Unallowable Medicare Payments for Chiropractic Services (2016) — Explains how an audit concluded that a chiropractic clinic in Michigan received least $339,000 over 2 years for services that were not allowable in accordance with Medicare requirementsCMS Should Use Targeted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic Services (2015) — Identified billing characteristics associated with undeserved payments and suggested ways to prevent such payments
- Alleviate Wellness Center Received Unallowable Medicare Payments for Chiropractic Services (2015) — Estimated that in 2012 and 2013, a chiropractic practice in California received at least $482,867 for services that were not allowable in accordance with Medicare requirements
- Advanced Chiropractic Services Received Unallowable Medicare Payments for Chiropractic Services (2015) — Estimated that a chiropractic practice in Kansas received overpayments of at least $737,111 for 2011 and 2012.
- Diep Chiropractic Wellness, Inc., Received Unallowable Medicare Payments for Chiropractic Services (2013) — Estimated that in 2012 and 2013, a chiropractic practice in California received at least $708,022 for services that were not allowable in accordance with Medicare requirements
- Inappropriate Medicare Payments for Chiropractic Services (2009) — Examined why Medicare has continued to pay inappropriately for maintenance care
- Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis (2005) — Examined the underlying causes of overpayment and ways to reduce them
- Chiropractic Care: Comparison of Medicare Managed Care and Fee-For-Service (2000) — Found that chiropractic utilization was lower in Medicare managed care risk plans than in fee-for-service plans
- Utilization Parameters for Chiropractic Treatments (1999) — Predicted impact of doing utilization review of chiropractic claims after 18 vs after 12 spinal manipulations per year
- Chiropractic Services Covered by Medicare Managed Care Organizations (1999) — Examined policies for providing chiropractic services in managed care plans
- Chiropractic Care: Controls Used by Medicare, Medicaid, and Other Payers (1998) — Recommended tighter utilization review to prevent unauthorized payments for chiropractic maintenance treatments
- Chiropractic Care: Medicaid Coverage (1998) — Recommended tighter utilization review to prevent unauthorized payments for chiropractic maintenance treatments
- State Licensure and Discipline of Chiropractors — (1989)
Recommended that state licensing boards be given increased funding and regulatory power
- Chiropractic Services under Medicare (1986) — Recommended opposition to expanding chiropractic coverage to include an initial diagnostic visit, x-ray or laboratory services, or adjunctive services
This page was revised on February 18, 2017.