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Can Physical Therapists Be Barred
from Treating "Subluxations"?

Stephen Barrett, M.D.

On January 15, 2001, the Centers for Medicare & Medicaid Services (CMS) declared that Medicare+Choice organizations "may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation." (See letter below.) The American Physical Therapy Association has responded with a letter seeking clarification. The problem has arisen because in the early 1970s, Congress amended the Medicare law to include coverage for "manual manipulation of the spine to correct a subluxation of the spine . . . which has resulted in a neuromuscular condition for which such manipulation is appropriate." To enable payment, chiropractors held a consensus conference that produced a 7-page document defining 18 types of "subluxations," many of which are fancy terms for the minor degenerative changes that occur as people age and are not changed by chiropractic treatment. Despite the inherent absurdity, chiropractors got paid because the Social Security Administration believed that Congress had intended that they be paid.

The significance of the CMS letter is unclear. Scientific practitioners (medical doctors and physical therapists) define "subluxation" as incomplete or partial dislocation -- a condition in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. No such condition can be corrected by chiropractic treatment. The vast majority of chiropractors use the term to mean other things. Some describe subluxations as "bones out of place" and/or "pinched nerves"; some think in terms of "fixations" or loss of joint mobility; and some occupy a middle ground that includes any or all of these concepts. Physical therapists are justified in seeking to preserve their right to perform manual manipulation to relieve back and neck discomfort. They do not actually treat any type of subluxation. However, it remains to be seen whether the semantic tangle created by the Medicare law will be used to restrict them.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OPERATIONAL POLICY LETTER #23

Date Issued: Revised - January 15, 2402 (Revision. of December 14, 1994)
Operational Policy Letter #: OPL 2002.023
To: Current M+C Organizations
Subject: Manual Manipulation of the Spine to Cover Subluxation -- Medicare Coverage
Effective Date: January 15, 2002
Implementation Date: January 15, 2002

Operational Policy Question:

Which practitioners are authorized by law to perform manual manipulation of the spine to correct a, subluxation as a Medic-are-covered service?

Answer:

Section 1861(r) of the Social Security Act provides the definition of a physician for Medicare coverage purposes, which includes a chiropractor for treatment of manual. manipulation of the spine to correct a subluxation. (As a standard Medicare Part B benefit, manual manipulation of the spine to correct a subluxation must be made available to enrollees in all Medicare, + Choice plans.) The statute specifically references manual manipulation of the spine to correct a subluxation as a physician service. Thus, Medicare + Choice organizations must use physicians, which include chiropractors, to perform this service. They may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation. Medicare + Choice organizations may continue to use physical therapists to treat enrollees for conditions not requiring physician services as defined in section 1861(r) of the Social Security Act,

Contact: CMS Regional Office Managed Care Staff

This OPL was prepared by the Center for Beneficiary Choices.

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This article was posted on February 12, 2002.