[Federal Register Volume 70, Number 18 (Friday, January 28, 2005)]
[Notices]
[Pages 4130-4132]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-1505]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-5037-N]


Medicare Program; Demonstration of Coverage of Chiropractic 
Services Under Medicare

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice announces the implementation of a demonstration 
mandated under Section 651 of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173), 
which will expand coverage of chiropractic services under Medicare 
beyond the current coverage for manipulation to correct a 
neuromusculoskeletal condition. Chiropractors will be permitted to bill 
Medicare for diagnostic and other services that a chiropractor is 
legally authorized to perform by the State or jurisdiction in which 
such treatment is provided. The demonstration will be conducted in four 
sites, two urban and two rural; one site in each area type must be a 
health professional shortage area (HPSA).
    Any chiropractor that provides services in these geographic areas 
will be able to participate in the demonstration. Any beneficiary 
enrolled under Medicare Part B, and served by chiropractors practicing 
in these sites would be eligible to receive services. Physician 
approval would not be required for these services. The statute requires 
that the demonstration be budget neutral. We anticipate that the 
demonstration will begin in April 2005 and operate for two years.

ADDRESSES:
    1. By Mail: Written inquiries regarding this demonstration must be 
submitted by mail to the following address:

[[Page 4131]]

Centers for Medicare & Medicaid Services, Attn: Sidney Trieger, 
Division of Health Promotion and Disease Prevention Demonstrations, 
Office of Research, Development, and Information, Centers for Medicare 
& Medicaid Services, S3-02-01, 7500 Security Boulevard, Baltimore, 
Maryland 21244-1850.
    Please allow sufficient time for mailed information to be received 
in a timely manner in the event of delivery delays.
    2. E-mail: Inquiries may be sent to the following e-mail address: 
[email protected].

FOR FURTHER INFORMATION CONTACT: Julie Jones, (410) 786-3039 or Sidney 
Trieger, (410) 786-6613.

SUPPLEMENTARY INFORMATION:

I. Background

    Section 651 of the Medicare Prescription Drug, Improvement and 
Modernization Act of 2003 (MMA) (Pub. L. 108-173) provides for a two-
year demonstration to evaluate the feasibility and advisability of 
covering chiropractic services under Medicare. These services extend 
beyond the current coverage for manipulation to correct 
neuromusculoskeletal conditions typical among eligible beneficiaries, 
and would cover diagnostic and other services that a chiropractor is 
legally authorized to perform by the State or jurisdiction in which the 
treatment is provided. Physician approval would not be required for 
these services. The demonstration must be budget neutral and will be 
conducted in four sites, two rural and two urban; one site of each area 
type must be a health professional shortage area (HPSA).
    Current Medicare coverage for chiropractic care is limited to 
manual manipulation of the spine to correct a subluxation, which 
chiropractors define as a malfunction of the spine. The three currently 
covered CPT codes are 98940 (manipulative treatment, 1-2 regions of the 
spine), 98941 (manipulative treatment, 3-4 regions of the spine), and 
98942 (manipulative treatment, 5 regions of the spine).
    Treatment must be provided for an active subluxation and not for 
prevention or maintenance. Treatment of the subluxation must be related 
to a neuromusculoskeletal condition where there is a reasonable 
expectation of recovery or functional improvement. Chiropractors are 
required to document the patient's complaint and establish a treatment 
plan, which includes the expected duration and frequency of treatment, 
specific goals and measures of effectiveness. This information must be 
maintained in the medical record and made available to Medicare upon 
request. Patients do not need a medical physician referral for 
treatment by a chiropractor under fee-for-service; some Medicare 
Advantage (MA) plans may require an enrollee to obtain a referral 
before seeing a chiropractor. In addition, some MA plans do not have 
chiropractors in their networks and allow osteopaths to provide 
manipulative services.

II. Provisions of the Notice

A. Covered Services

    To determine which services will be covered, we conducted a 
literature review of the evidence of the effectiveness of chiropractor 
services. We held discussions with the American Chiropractic 
Association (ACA) and also reviewed the current coverage of 
chiropractor services with the Department of Defense and the Veterans 
Administration. In addition, we convened an Open Door Forum in November 
2004 to invite comments on our proposed design for the demonstration. 
Based on these discussions, the evidence for effectiveness of 
chiropractic care, and current Medicare policy, the following 
guidelines for the demonstration were developed:
    1. Services must be related to active treatment, not maintenance or 
prevention. This follows current Medicare coverage for similar 
services, such as physical therapy. Medicare does not authorize payment 
for maintenance therapies for other providers. We will require that all 
claims under the demonstration will have the active therapy (AT) 
modifier.
    2. The demonstration will expand the services chiropractors are 
allowed to provide in the demonstration only to treatment of 
neuromusculoskeletal conditions, but not to other conditions. We have 
found no literature that provides conclusive evidence that chiropractic 
services are effective for treatment of other diagnoses.
    3. Under the demonstration chiropractors can provide plain x-rays, 
electromyography (EMG) tests and nerve conduction studies; order 
magnetic resonance imaging (MRI) scans and computed tomography (CT) 
scans; as well as order or provide laboratory tests (where the 
applicable State practice act permits chiropractors to provide these 
services). These diagnostic services are related to the diagnosis and 
treatment of neuromusculoskeletal conditions. No limits will be imposed 
on chiropractors for providing diagnostic services, unless limits exist 
for other providers delivering these services.
    4. The demonstration will cover CPT code 98943 for extraspinal 
manipulation, as it is a recognized procedure for treating 
neuromusculoskeletal conditions. It will also expand coverage to 
include other services chiropractors are legally allowed to provide and 
Medicare currently covers. These procedures include electrotherapy, 
ultrasound, transcutaneous electrical nerve stimulation (TENS) therapy, 
and other services that are medically necessary for the treatment of 
neuromusculoskeletal conditions. Chiropractors delivering these 
services will be subject to the same payment policies as other Medicare 
clinicians currently delivering these services. These requirements can 
be found in the Medicare Benefit Policy Manual 100-2 in Chapter 15, 
Sections 220 and 230 and the Medicare Claims Processing Manual 100-4 in 
Chapter 4, Section 20 and other manual sections. For example, physical 
and occupational therapy services must be identified through the use of 
modifiers GP and GO respectively. Chiropractors will also be allowed to 
make referrals for these therapy services.
    5. Chiropractors would also be reimbursed for evaluation and 
management (E&M) services delivered for neuromusculoskeletal 
conditions.
    Under the demonstration, chiropractors would be allowed to bill 
Medicare for treatment in addition to an E&M visit on the same day the 
first time they assess a patient, and thereafter only when they assess 
a patient for a new, separate problem not currently being treated. The 
current E&M CPT codes will apply.
    We will require chiropractors to submit claims for demonstration 
services separately from claims for currently covered services (CPT 
codes 98940, 98941, and 98942). Chiropractors will have to add 
demonstration code 45 to all demonstration claims in order to be 
reimbursed for demonstration services.

B. Managed Care Plans

    The legislation requires that the same demonstration benefits be 
offered under MA plans as for Medicare fee for service beneficiaries. 
Because participation of managed care plans is voluntary, we cannot 
require plans to participate in the demonstration. We therefore plan to 
approach MA plans in the demonstration site areas to determine if they 
would offer demonstration services to beneficiaries, but we will not 
change the MA plan rates since the demonstration is required to be 
budget neutral.

[[Page 4132]]

C. Payment Rates

    The payment rates for demonstration services will be the same as 
under the physician fee schedule.

D. Budget Neutrality

    The statute requires the Secretary to ensure that the aggregate 
payments made under the Medicare program do not exceed the amount that 
would have been paid under the Medicare program in the absence of this 
demonstration.
    Ensuring budget neutrality requires that the Secretary develop a 
strategy for recouping funds should the demonstration result in costs 
higher than would occur in the absence of the demonstration. We will 
first determine over the two-year demonstration whether the 
demonstration was budget neutral. If the demonstration is not budget 
neutral, we plan to meet the legislative requirements by making 
adjustments in the national chiropractor fee schedule to recover the 
costs of the demonstration in excess of the amount estimated to yield 
budget neutrality. We will assess budget neutrality by determining the 
change in costs based on a pre-post comparison of costs and the rate of 
change for specific diagnoses that are treated by chiropractors and 
physicians in the demonstration sites and control sites. We will not 
limit our analysis to reviewing only chiropractor claims because the 
costs of the expanded chiropractor services may have an impact on other 
Medicare costs.
    A CMS evaluation contractor will conduct the analysis of claims and 
budget neutrality. Since it will take approximately two years to 
complete the claims analysis, we anticipate that any necessary 
reduction will be made in the 2010 and 2011 fee schedules. If we 
determine that the adjustment for budget neutrality would be greater 
than two percent of the chiropractor fee schedule, we will implement 
the adjustment over a two-year period. However, if the adjustment is 
less than two percent of the chiropractor fee schedule, we will 
implement the adjustment over a one-year period. We will include the 
detailed analysis of budget neutrality and the proposed offset in the 
2009 Federal Register publication of the physician fee schedule.
    We invite comments regarding the appropriate methodology for 
determining budget neutrality. Written materials may be submitted by 
mail or e-mail to the addresses listed in the ADDRESSES section of this 
notice.

E. Site Selection

    The statute requires that this demonstration be conducted in four 
sites--two rural and two urban; one site in each type of area must be a 
health professional shortage area (HPSA). We have selected:
     26 northern counties in Illinois which includes Cook, 
Dekalb, DuPage, Grundy, Kane, Kendall, McHenry, Will, Boone, Bureau, 
Carroll, Henry, JoDaviess, Kankakee, Lake, LaSalle, Lee, Marshall, 
Mercer, Ogle, Putnam, Rock Island, Stark, Stephenson, Whiteside, and 
Winnebago, and Scott county in Iowa (urban);
     17 central HPSA counties in Richmond, Charlottesville, 
Lynchburg, and Danville MSAs in Virginia (urban HPSA)--the Virginia 
counties include Pittsylvania, Campbell, Appomattox, Nelson, 
Buckingham, Fluvanna, Louisa, Caroline, Hanover, New Kent, Henrico, 
Richmond City, Goochland, Cumberland, Powhatan, Amelia and Danville 
City;
     New Mexico (rural HPSA); and
     Maine (rural).
    We first grouped States by Medicare carriers, because we determined 
it was important that control and experimental sites should have the 
same carriers (since some carriers impose limits on chiropractor claims 
they approve). We then determined appropriate sites based on the 
following criteria:
     Exclude States with restrictive practice regulations.
     Exclude States that will not have transitioned to the MCS 
system in time for the demonstration.
     Exclude States that are ranked in the top or bottom 5 
values for two or more of the following six statistics:

--Medicare per capita claims costs
--Medicare per capita chiropractic costs
--Per user (patient) chiropractic costs based on carrier data
--Chiropractic service users as a percentage of Part B beneficiaries

--Chiropractors per 10,000 State population
--Chiropractors per 1,000 Part B beneficiaries

     Exclude States among those remaining that are served by a 
unique carrier and, thus, would lack a potential comparison site.
     Each carrier group was assessed to determine its ability 
to support treatment and comparison groups for one or more types of 
sites.
     Data was then used to estimate the number of beneficiaries 
residing in Urban/Rural and HPSA/non HPSA areas and determine which of 
the remaining States could support a demonstration site or sites.
    Few States had enough beneficiaries residing in HPSAs to be 
considered for one of the HPSA demonstration sites.

III. Collection of Information Requirements

    This document does not impose information collection and record-
keeping requirements. Consequently, it does not need to be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995.

    Authority: Section 651 of the Medicare Prescription Drug 
Improvement and Modernization Act of 2003 (Pub. L. 108-173).

(Catalog of Federal Domestic Assistance Program No. 93.778 and No. 
93.774, Medicare--Supplementary Medical Insurance Program)

    Dated: December 17, 2004.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 05-1505 Filed 1-27-05; 8:45 am]
BILLING CODE 4120-01-P