CMS Pub. 100-02, ch. 15, § 240.1.3

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.

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.

For Medicare purposes, a chiropractor must place an AT modifier on a claim when

providing active/corrective treatment to treat acute or chronic subluxation. However the

presence of the AT modifier may not in all instances indicate that the service is

reasonable and necessary. As always, contractors may deny if appropriate after medical

review.

A. Maintenance Therapy

Maintenance therapy includes services that seek to prevent disease, promote health and

prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic

condition. When further clinical improvement cannot reasonably be expected from

continuous ongoing care, and the chiropractic treatment becomes supportive rather than

corrective in nature, the treatment is then considered maintenance therapy. The AT

modifier must not be placed on the claim when maintenance therapy has been provided.

Claims without the AT modifier will be considered as maintenance therapy and denied.

Chiropractors who give or receive from beneficiaries an ABN shall follow the

instructions in Pub. 100-04, Medicare Claims Processing Manual, chapter 23, section

20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.

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 hyper mobility 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.