Medicare Compliance & Reimbursement

Medicare has made an age-old chiropractor-radiologist relationship obsolete effective Jan. 1.

The 2008 Medicare Physician Fee Schedule Final Rule has removed the longstanding "chiropractor exception," which allowed radiologists to order and bill for x-rays requested by chiropractors.

Prior to Jan. 1, 2000, the Centers for Medicare & Medicaid Services (CMS) required chiropractors to demonstrate subluxations via x-ray. "Because chiropractors are limited by statute in the services they can provide under Medicare," the Final Rule states, "it was necessary to create an exception" to the rule that x-rays had to be ordered by the treating physician.

Therefore, the exception allowed nontreating physicians (such as radiologists) to order and collect payment for x-rays that chiropractors used.

"However, in 2000, Medicare scrapped the requirement that subluxations had to be demonstrated on x-ray, so the exception was no longer necessary," says Kendall Brill, who bills chiropractic claims for Brill Billing in Omaha.

"Despite that, the exception still existed," Brill says, "allowing radiologists to order and collect for x-rays on behalf of chiropractors."

"Eliminating the exception is a disappointment," says David Deems, DC, a chiropractor in New York, NY. "We may not need an x-ray to diagnose every spinal subluxation, but we do need x-rays for other conditions."

In fact, the Final Rule states that several commenters noted that "the ability to obtain an x-ray for Medicare beneficiaries is critical to providing responsible, safe, and medically prudent care."

But CMS argued back, saying that the chiropractic exception never allowed for x-rays other than those to diagnose subluxations, and that other x-ray uses are "outside the scope of covered chiropractic services" anyway.

"This is a frustrating decision, but it may make billing easier," Brill says. "In the past, we had to sort out which x-rays were billable under Medicare for chiropractic services and which were unrelated to subluxations and therefore weren't covered. Now we know not to bill Medicare for them in the first place."

To read CMS' explanation of removing the chiropractor exception, go to page 601 of the Medicare Physician Fee Schedule Final Rule at http://www.cms.hhs.gov/PhysicianFeeSched/downloads/CMS-1385-FC.pdf