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Select a PolicyACA SUPPORT OF THE APHA CHIROPRACTIC SECTION 2010 POLICY STATEMENT ON MUSCULOSKELETAL DISORDERS AS A PUBLIC HEALTH CONCERN
THEREFORE BE IT RESOLVED, that the ACA supports the 2010 policy of the Chiropractic Section of the APHA titled “Musculoskeletal Disorders as a Public Health Concern: APHA Response and Action Steps”
ACA SUPPORT FOR ANTIDISCRIMINATION LANGUAGE IN THE PATIENT PROTECTION AND AFFORDABLE CARE ACT.(PPACA)
Resolved, That the ACA condemns the following discriminatory practices which are deleterious to the public health and may unnecessarily increase the cost of health care: 1. Discriminatory policies of third party payers or other entities toward patients and chiropractic physicians, relative to reimbursement for the full-scope of chiropractic services as established by state/territorial regulatory bodies. 2. Discriminatory policies of third party payers or other entities that attempt to restrict access to the full scope of chiropractic professional services and care. 3. Discriminatory policies of third party payers or other entities which do not provide for reimbursement for chiropractic physicians in parity with the reimbursement levels of other physician-level providers for the same professional services.4 4. Arbitrary discrimination that limits full reimbursement by any third party payer or other entity for services provided by a chiropractic physician Be it further resolved: That the American Chiropractic Association continues to oppose any legislation that is contrary to full scope reimbursement as determined by federal, state and territorial statutes, rules or regulations.
In addition to providing seats that are ergonomically designed, it is further recommended that airlines continue to increase the distance between seats (from front to back and side to side).
The ACA further proposes that the airline industry utilize members of the chiropractic profession who have specialized training in the field of safety ergonomics and exercise to assist in the design of seats and exercise programs aboard airlines in an effort to reduce health care issues aboard flights. (Ratified by the House of Delegates, September 2004).
WHEREAS, the APHA in 1983 superseded its former anti-chiropractic policy with a new policy that recognized chiropractic as safe and effective for neuromusculoskeletal conditions and in particular for disorders of the low back; and,
WHEREAS, the APHA in 1995 established its Chiropractic Health Care section having full equity and parity with all the other multidisciplinary sections in the APHA; and
WHEREAS, the APHA has continued to recognize, support, and encourage chiropractic participation within APHA; and,
WHEREAS the APHA has been shown to be one of the most effective vehicles for integrating the chiropractic profession into mainstream public health activities; and,
WHEREAS, the ACA adopted a resolution in 1983 urging all ACA members and all chiropractors to join the APHA; and,
WHEREAS, the ACA has been an official Agency Member of the APHA continuously since 1984; and,
WHEREAS, the ACA has established and funded a standing ACA Committee on APHA for many years; and,
WHEREAS, the Association of Chiropractic Colleges (ACC) is also an official Agency Member of the APHA;
THEREFORE, the ACA House of Delegates hereby reaffirms its support for the APHA and issues this 2008 resolution encouraging all ACA members and all Doctors of Chiropractic to join and maintain membership and become active in the APHA henceforth.
(Ratified by the House of Delegates, September 2012)
(Ratified by the House of Delegates, September 2013)
The American Chiropractic Association House of Delegates approves the following policy/guide concerning chiropractic health care discount programs.
In many states, these types of programs are regulated. A provider should demonstrate due diligence by determining first whether there are any laws or regulations in place that are applicable to the type of program the provider is considering and whether the particular program adheres to those laws and regulations.
Consideration should be made for the motivation for joining such a program. A provider should ask themselves whether they are considering joining the program for the best interests of their patient population.
Providers should heed caution when using a discount program in conjunction with, or in lieu of, a patients Medicare benefits.
Similarly, caution should also be observed when using a discount program in conjunction with or in lieu of third party payers and managed care organizations.
Providers should completely review contracts and investigate the policies in place for renewal and cancellation of policies for both the provider and the patient to determine their rights under the contract.
Resolved, that the ACA will seek out other health care professional organizations to form a united coalition in order to help bring this legislation to fruition. (Ratified by the House of Delegates, March 2002).
1. There should be a universal eligibility for the appropriate health care for all U.S. citizens, regardless of income or ability to pay.
2. There should be a full range of licensed health care services (e.g. medicine, osteopathy, chiropractic, dentistry, psychology) available to the consumers (patients) in all-federal programs. The consumer should be guaranteed freedom of choice in the selection of a licensed health care provider without discrimination against the consumer or any licensed health care provider he may choose.
3. When appropriate, ambulatory or out-patient care should be encouraged over more expensive and in some cases less effective hospitalization or in-patient care.
4. Based on the growing amount of scientific evidence that supports the clinical effectiveness, cost-effectiveness and relative safety of chiropractic care it should be included in the mainstream of the nation's health care system. There is an established need for federal emphasis and support of research and research training programs in chiropractic. Without creating new programs, existing ones could be broadened to reach these needs (e.g. NIH, AHCRP, HRSA). Additionally, it is appropriate and necessary to include qualified doctors of chiropractic in public/federal activities that involve health care policy development and implementation.
5. Medicare or Medicaid patients that choose chiropractic health care should not be discriminated against. They should be allowed full coverage of those chiropractic services that are conterminous with state licensure.
6. Under all federal health care programs, all supportive health care services (e.g. clinical laboratory, diagnostic imaging, neurodiagnostics) should be equally available to all licensed health care providers without discrimination, provided they fall within their scope of practice.
7. In all federal health care programs there should be conformity to uniform standards for all health care intermediaries or carriers functioning in those programs. Such standards should include, but not be limited to eligibility, coverage, utilization, etc. Additionally, there should be uniform quality assurance programs that are not discriminatory toward certain professions.
8. The health care consumer in all health care programs, Federal or private, must have direct access to chiropractic care. Chiropractic is traditionally considered an alternative and therefore a "competitor" to medicine. Since formal medical training does not typically include the integration of chiropractic, it is unreasonably discriminatory, not cost effective and potentially monopolistic to make chiropractic services available to the health consumer only on medical prescription.
9. The doctor of chiropractic, as with all licensed health care providers, is obligated to seek consultation with or referral to other appropriate health care providers (e.g. MD, dental, chiropractor) if a patient's complaints or condition are not suitable for that chiropractor's care.
10. In the interest of providing quality health care there should be an established peer/utilization review mechanism for all federally supported or administered health care programs. Where applied, peer review should be conducted by members of the same profession with consumer interests represented.
11. In the interest of quality assurance, there should be continuing education with certification procedures that require demonstration of ongoing professional competency for all licensed health care providers.
12. In the advent of managed care there is evidence that some health care professionals or specialties are still numerically deficient or inadequately distributed. Most of these shortages occur in those providers that supply first contact (portal of entry) care. Since chiropractic serves as a first contact health care profession it is in the public interest to provide federal funding for chiropractic education. Such educational support should be universal for all underserved professions with obligations for those who accept this support to provide service for an appropriate period in underserved geographic areas at a reasonable remuneration.
Additionally, in post-graduate programs where there is federal support or special incentives to universities that provide these programs there should be emphasis to make these programs non-discriminatory. Therefore, these programs should be equally available to all licensed health care professionals. (Ratified by the House of Delegates June 1998).
Resolved, that the ACA also supports other types of educational activities utilizing materials such as CD-ROMs, DVDs, power-point presentations, printed educational materials, audiotapes, video cassettes, films, slides, journal club activities, journal-based CME, teleconferences, web based and computer-assisted / online educational instruction that provide a clear, concise statement of the educational objectives and indicate the intended audience. These programs shall also have a method of verifying practitioners' participation.
Many in-state and out-of-state review organizations arbitrarily delete the "office call of the day" (900XX series) as non-reimbursable, since the chiropractic profession has not set a policy on this matter. Many chiropractic physicians consistently utilize only one code, such as 97260, billing in a global fashion and failing to itemize specific services. This may result in the inequitable practice of rendering a uniform charge to all patients, thus under-charging or over-charging certain patients who undergo differing procedures.
Therefore, be it resolved that ACA encourage the correct itemization of services and procedures under accepted CPT code numbers, in accordance with federal and state statute or administrative rule. (Ratified by the House of Delegates, June 1991).
For additional information, a CPT Recommendations Booklet is available from ACA.
The cytotoxic leukocyte test is also tedious and time-consuming, two factors that render the procedure impractical and costly. Interpretation of the test is also highly subjective so that the training and experience of technicians performing the procedure may assume major importance with respect to its accuracy and reproducibility. (Ratified by the House of Delegates, June 1986).
The quality of ultrasound images is extremely dependent on operator skill. The resolution abilities of the equipment may have an impact on diagnostic yield and accuracy. Consequently, the importance of training to establish technologic as well as interpretive competency cannot be understated. The application of diagnostic ultrasound in the adult spine in areas such as disc herniation, spinal stenosis and nerve root pathology is inadequately studied and its routine application for these purposes cannot be supported by the evidence at this time.
Be it further resolved that the House of Delegates recommend the American Chiropractic College of Radiology re-evaluate annually diagnostic ultrasound and report to the House of Delegates. (Ratified by the House of Delegates, May 1996).
Resolved, that doctors of chiropractic serving at the local disaster level acquire Basic Disaster Skills, and that doctors of chiropractic seeking service as a member of a state or national disaster team for deployment to larger emergencies be cross-trained and certified in advanced emergency care. Full text available on request. (Ratified by the House of Delegates, March 2003).
Clinical (Medical) Documentation Recommendations Based on these findings and trends, the ACA recommends certain basic requirements be considered as appropriate medical documentation in patient record keeping. A concerted effort by the chiropractic profession to standardize medical documentation will improve the frustration level and reimbursement experience exponentially.
1. The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed.
2. Subjective, Objective, and Treatment, if rendered, components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted.
3. All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors.
4. Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined.
5. Documentation for the initial
(new patient) visit, new injury or exacerbation should consist of the History and Physical and the anticipated Patient Treatment Plan. The initial Treatment Plan except in chronic cases should not project beyond a 30-45 day interval. Subsequent
patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan need to be re-evaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate.
6. If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care.
7. Records can be attached to each billing to pre-empt requests, however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not).
8. All records must be legible and understandable, released within the authority given by the patients, in a secure confidential manner, and in compliance with existing state (or federal) statutes.
9. The patient name and initials of the person making the chart notation (especially in multipractitioner offices) should appear on each page of the medical record.
10. If the above recommendations have been met then the answers as to why the necessity for continuing treatment is answered.
11. The insurance industry must improve their claim adjusting procedures by utilizing chiropractic consultants. The ACA can use its resources to assist in this initiative. (Ratified by the House of Delegates, September 2000).
Resolved, that the American Chiropractic Association through the Insurance and Managed Care Committee work with the different third party payors to establish and utilize a uniform set of forms, when additional documentation is required by the third party payor in support of claims submission. (Ratified by the House of Delegates August 2002)
Resolved, that the domestic violence legislation should include a physician indemnification section regarding the reporting of suspected domestic violence to protect the physician against any retaliatory action that might be taken against the physician for the act of notification. (Ratified by the House of Delegates, August 1999).
Resolved, further, that the ACA emphasizes the highest ethical conduct in both research and patient care. (Ratified by the House of Delegates, June 1982).
The ACA supports the definition of evidence based medicine as:
|"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer."|
|Source: Sackett, D.L. et al. (1996), Evidence based medicine:
In response to medical literature of poor standards and extreme bias, the creation of practice guidelines is shifting to rely solely upon randomized clinical trials (RCTs), which have strong clinical evidence. This is problematic because the patient base often included in RCTs is taken from very restrictive groups of individuals. When guidelines are based on evidence that is representative of a narrow group of patients and those guidelines are applied unequivocally, a disconnect occurs, and patients do not receive the best treatment. Another unfortunate consequence of relying strictly on RCTs is that there is a lapse in time between valuable advances in therapies and completed RCTs. Providers should have the most proven up to date methods at hand to treat their patients, either by science or by clinical experience or a combination thereof. Best Practices, in contrast to restrictive clinical guidelines, allow for the integration of research and clinical expertise while respecting the unique nature of individual patients and are preferred due to their patient centered focus as opposed to guidelines that are meant to impose restrictions or limits on providers.
While RCTs are, without doubt, highly valuable clinical evidence, they have limitations and weaknesses when applied across the board. Because of this, it is important to take into review a variety of other clinical evidence information including case studies, cohort studies, literature reviews and historical performance for applicability and value when developing guidelines and patient care plans. Third party payers and providers have an obligation to the public to remain aware of new evidence that is released which may affect patient care.
The ACA is aware of over-utilization and questionable utilization of care that occurs in the health care delivery system. The ACA does not support those who engage in these actions nor does the ACA support guidelines developed by third party payers that draw upon out of date literature and impede the doctor-patient relationship through excessive management of providers. The ACA supports patient-centered healthcare that draws upon a provider's expertise and the available research while effectively and cost-consciously treating the patient. (Ratified by the House of Delegates, September 2004).
The American Chiropractic Association endorses and supports a universal program to encourage the aging public to begin and maintain an age appropriate exercise program to help prevent and/or reverse the trend of functional immobility and obesity and assist in ameliorating numerous chronic conditions. References available on request. (Ratified by the House of Delegates, September 2004).
The ACA holds the position that professional fees charged by the chiropractic physician and paid by the patient are a part of the doctor-patient relationship and does not advise nor condone interference with this relationship or other contractual relationships of the respective parties.
Reimbursement where third-party contracts call for reimbursement on the basis of usual, customary, and reasonable should be consistent with the customary fees of the profession in a given geographical and/or socioeconomic area.
Current reimbursement policy for chiropractic services under Medicare is not consistent with customary chiropractic practice. Such policy creates an economic hardship for the Medicare recipient and deprives the recipient of the greater benefits, which are available through customary chiropractic diagnostic and therapeutic procedures. (Approved, July 1975)
Resolved, that the American Chiropractic Association condemns the practice of arbitrarily limiting the scope of practice and/or professional care of Doctors of Chiropractic by any third party payer. These activities may represent a significant health hazard for patients who require chiropractic care. Doctors of Chiropractic should be allowed the latitude to employ the full scope of chiropractic services as established by their respective state statutes. Third party payers should reimburse for appropriate professional services performed by Doctors of Chiropractic if services performed by other physician-level providers are reimbursed for the care of same or similar conditions. Such professional services should be reimbursed in parity with the reimbursement levels of other physician-level providers. (Ratified by the House of Delegates, August 2001)
Resolved, that the American Chiropractic Association investigate the feasibility and utility of a study to determine if the Chiropractic profession as a whole is receiving the same type of contractual arrangements as other providers and if there is a pattern of frozen fee schedules among third party payors, and to determine what the cost of living clauses are, if any, in the major third party payors for the chiropractic profession. (Ratified by the House of Delegates August 2002) Waiver (NOOPE)
Resolved, that the ACA caution its members that it regards the practice of routine waivers of third-party payer deductibles and co-insurance amounts to be an unacceptable and possibly illegal method of patient inducement. A chiropractor should consult with his or her state licensing board, insurance carrier, Medicare/Medicaid carrier or personal legal representative to determine if such a waiver violates a statutory or regulatory prohibition. (Ratified by the House of Delegates, June 1990).
Healthcare fraud is everyone's concern. It exists, in some degree, in every Healthcare profession and in every area of the United States. As the nation's foremost and largest professional chiropractic association in the country, the American Chiropractic Association (ACA) takes a strong position against any form of healthcare fraud. Healthcare fraud can be defined as wantonly misleading or misrepresenting patient treatment circumstances or any other dynamic of the healthcare industry, resulting in any type of financial gain for the doctor, patient, or any other third party of entity. It is important to note that insurers who use unfair medical review practices that create obstacles to chiropractic access and reasonable and necessary care for patient constitutes fraud and abuse. The ACA opposes any type of fraud within the chiropractic profession and within the insurance industry; third party payers, managed care organizations or other entities where restrictive and unfair reimbursement practices toward the chiropractic profession exist. However, the ACA will continue to work with both the insurance industry to ensure the equal treatment of Doctors of Chiropractic, and with the chiropractic profession to educate doctors as to What may constitute fraud and/or abuse." (Ratified by the House of Delegates, August 2001).
Fraud and Abuse Medical Review Benchmarks Policy
Public concern over the incidence of provider fraud and its impact on quality of care and higher insurance premiums is increasing. This is creating heightened accountability for both insurers and providers in the area of fraud and abuse control. Even certain state laws require insurers to implement anti-fraud programs as part of their regulatory compliance. Based on these market conditions, it is to the advantage of both the insurance industry and all health care professionals to cooperatively identify and eliminate potentially fraudulent and abusive activities due to its negative impact on the insuring public and the image of all health care professionals.
To this end, the American Chiropractic Association recommends a policy statement founded on the following business approach:
In addition to cost savings, public messages around fraud/abuse elimination need to reflect insurer and provider interest in bettering the healthcare delivery system to ensure the provision of quality care for insured patients.
Certain criteria must exist to consider or otherwise reference a situation as potentially fraudulent. Fraud is defined as an intentional misrepresentation where these conditions are present:
- There must be a cause of deception.
- The act or acts must show an intentional misrepresentation of fact.
- The provider stands to gain financially from the deception and misrepresentation.
Abuse differs from fraud in that it describes incidents or practices of providers that are inconsistent with accepted sound clinical, business or fiscal practices (including but not limited to excessive or unnecessary care, improper business practices, poor clinical documentation, coding and billing mistakes) but that are not knowingly or intentionally misrepresented facts to obtain payment.
Fraud and Abuse Identification:
Retrospective reviews referred for investigation require a sound basis for suspecting fraud/abuse and should not target any profession. A professional opinion by a peer in the same state and in the same specialty may be indicated.
Data mining, pattern software or other methodologies to identify potential fraud/abuse can be used to show deviations from the standard of care within the community. The investigation of the cause behind the deviation from the standard of care will take into account the accepted practices for the provider type identified.
Data considered to represent outlier behavior may not represent wrongdoing and requires an explanation from the treating provider. The case mix complexity needs to be considered as do other patient complications including condition, age, co-morbidity and severity of injury etc.
Post payment review/retrospective utilization review or other fraud and abuse audits should be based on the insurers' policies and procedures that were in effect at the time the services were provided.
No financial incentive may exist for a fraud/abuse referral, investigation or recovery however, it is understood that insurers must cooperate with state and federal agencies as requested. These policies and procedures should be arrived at with peer input and in a scientifically and legally defensible manner, and should be clearly communicated to providers.
License and Billing Requirements:
Doctors of chiropractic should hold a current license in good standing and use proper codes and billing intent for both diagnosis (ICD-CM) and treatment codes (CPT). Treating providers should direct patient care including the ordering of tests and other services subject to the medical necessity for each patient. A provider should review billings before they are submitted to insurers to ensure there is supporting clinical documentation for all services and treatments.
Qualifications for Fraud/Abuse Reviewers and Investigators:
Internal insurance reviewers and field investigators and coordinators should be knowledgeable in the chiropractic field and understand specific CPT coding used by doctors of chiropractic including Evaluation and Management, Physical Therapy and Rehabilitative Services, Manipulation and Diagnostic Imaging. Attention to the state scope of practice is needed. Specific experience in a variety of health care related fields is recommended including but not limited to:
- Terminology and Abbreviations
- Care Definitions
- Content and Interpretation of Clinical Records
- Claim Administration Policy and Procedure
- Fair-minded Medical Review Practices
- Compliance with State Claim Handling Regulatory Requirements
- Privacy, Disclosure and Confidentiality Protection
Communications Surrounding Fraud/Abuse Investigations:
Insurer policies may be superimposed by federal or state criminal policy for fraud actions, however, for abuse situations, communications should not intimidate the provider on any level, during or in the course of an investigative procedure, including but not limited to the provision of necessary care for the patient. Dialog should be directly between the insurer and the provider and not involve the patient, office staff or other parties unless those parties have filed a formal inquiry with the insurer as to the nature of a potentially abusive situation. Other formalities need to exist including:
- No unannounced on-site visits and the use of best efforts to find a mutually agreeable time to meet.
- Adequate notice to the provider about an emerging abuse or a subsequent investigation, including the rationale for the investigation.
- Notification to be provided no longer than 6 months following the receipt of the final bill.
- Arranging for payment of billings not in question.
- Provision for provider to submit supplemental information and to contest the findings.
- Periodic (30 day) status of the investigation sent to the provider.
- Written final investigative report to be sent to the provider outlining the areas of disparity.
- Willingness to resolve conflict in a reasonable time frame.
- Access to the investigator for discussion purposes.
The treating provider should cooperate in the submission of records and be responsive to the above conditions in an effort to resolve the issue at hand in a reasonable time frame. Investigative staff and treating providers will conduct themselves in a professional way throughout the process.
Reimbursement and Recovery:
When the insurer, outside investigative agency and the treating provider agree funds are recoverable, it will be subject to the following terms:
- Funds may be recoverable for 3 months, prior to the time of audit notification to the provider.
- For amounts not to exceed the plan reimbursement level for said services.
- For only those services that are in question on actual claim payouts.
- Less services that may not have been billed the provider can document.
- Less reasonable copying fees incurred by the provider.
- All efforts should be made to resolve the agreed upon financial arrangement within 30 days unless otherwise agreed to by both parties.
- Any situations that may arise that are not covered under this document should be approached with a similar philosophy of direct and open dialog. Both the chiropractic profession and payer industry should attempt through various forums to find common ground to eliminate fraud. (ratified by the House of Delegates September 2004)
In consideration that genetically modified plant technology is at an early stage of development and since the scientific community acknowledges that the use of genetically modified plants is not without risk both to the environment and human health. The ACA supports the right of consumers not to be involuntarily subjected to possible risks by supporting the right of consumers to choose not to consume genetically modified foods through clear and informative labeling.
The ACA supports strong and effective regulatory control with comprehensive long term monitoring as part of an ongoing assessment as to the possible adverse effects on the environment, food chain and human health. (Ratified by the House of Delegates, September 2000). References available on request.
The American Chiropractic Association affirms the responsibility of the chiropractic profession separately and in concert with the allied health professions to provide all the people with optional and affordable health care under the democratic principles of freedom of choice and freedom from government control of the professions.
The American Chiropractic Association will continue to work for meaningful cost containment within the framework of a free society and under provisions that apply equally and uniformly to all segments of our economy. (Board approved, June 1984).
Resolved, that the ACA reaffirm chiropractic's leadership role in the promotion of the natural health care paradigm by:
1) Developing a presence in the appropriate periodicals, journals, and conferences
2) Taking additional steps to promote research beyond musculoskeletal conditions
3) Developing relationships through the media as experts in alternative and complementary procedures
4) Developing a relationship with professional organizations to foster and exchange ideas and to further understand their disciplines
5) Developing a committee to investigate and report to the public and our membership on alternative and complementary health care techniques and procedures. (Ratified by the House of Delegates, June 1998).
(1) Good housing and proper sanitary facilities, including waste water disposal and garbage removal;
(2) Good nutrition, including safe and healthful foods;
(3) Good public environment, including freedom from air and water pollution, from toxic chemicals, and from communicable diseases;
(4) Good working environment, including freedom from exposures to industrial accidents and occupational health hazards;
(5) Good life style, including freedom from deleterious effects of smoking, drugs, and alcohol, and reduction of traffic accidents and injuries;
(6) Good health attitudes and widespread use of preventive health care techniques and facilities.
In the long run, factors such as above outlined and others may be more important health programs than health care delivery itself, and the nation's health care delivery system must be developed for appropriate coordination with all these factors affecting good health. Thus, good health is broader than the health care industry itself. Furthermore, good health is not dependent upon the control of any one segment of the health care industry over the other participants. The health care industry must not be subject to the monopoly of medical doctors; all licensed health care providers (including doctors of chiropractic) must be regarded as having a valid role to play in the health care delivery system, to the degree of their licensed authority. (Guidelines for National Health Planning Goals, Approved, November 1975).
Resolved, that the House of Delegates adopt the "Building Blocks for Healthy Eating" as the American Chiropractic Association's dietary guidelines. (Ratified by the House of Delegates, August 1999). Note: Full text available from ACA.
Resolved, that ACA sort out the essential elements of HIPAA, which are relevant to our members. Be it further
Resolved, that ACA offer a simplified, straightforward list of essential elements and action steps for compliance. Be it further
Resolved, that ACA strongly encourage all ACA members to file an extension prior to October 16, 2002, to give them another year to become compliant with all final HIPAA issues. (Ratified by the House of Delegates, August 2002).
Confidentiality of the HIV infection status of patients and staff must be maintained with disclosure limited to situations defined by local laws, statutes or regulations.
The ACA encourages state chiropractic associations to conduct periodic HIV education sessions and to develop resources for chiropractors and their staff. Specific annual training mandated by OSHA must be provided by employers with employees whose duties put them at risk of exposure to blood borne pathogens. Patient education efforts are encouraged, as well. (Ratified by the House of Delegates, July 1994). (The text printed above is an abstract of a policy statement ratified by the House of Delegates, July 1994. A copy of the complete policy statement can be obtained from ACA Headquarters).
The following guidelines are proposed for those chiropractors seeking to be integrated into the established hospital system.
We must fit into the existing mechanisms, plans and protocols of hospital staffing.
Hospital staff members generally stay within their limited specialties and call upon consultants for problems outside those specialties.
Chiropractic doctors will secure entrance into hospitals only by working within the system.
The logical point of entry is to seek admission for the neuromusculoskeletal disorders most commonly treated by the majority of our chiropractic colleagues. We would perform related examinations, order related X-rays, perform manipulative procedures (adjustments), order physical therapy, and other supportive measures all within the scope of existing state laws governing the practice of chiropractic. In conjunction with the committee's general objectives and stated guidelines, additional currently limited objectives are recommended:
Within the legal scope of practice, utilization of diagnostic facilities and procedures for responsible differential diagnosis as essential to management, co-management or referral of the patient.
Utilizing chiropractic manipulation, physical therapy, external immobilization and nutrition where applicable.
Providing, where needed, training in hospital protocol and procedures through CCE approved programs in our accredited colleges.
Provide for screening procedures of chiropractic applicants with consideration of education, training, scope of practice, reputation and ability to work in harmony with medical and other hospital personnel.
Referring to medical specialists for management of infectious, neoplastic or primary neurologic disease. (Ratified by the House of Delegates, June 1983).
Evans MW, Jr., Ramcharan M, Floyd R, Globe G, Ndetan H, Williams R, et al. A proposed protocol for hand and table sanitizing in chiropractic clinics and education institutions. J Chiropr Med. 2009 Mar;8(1):38-47.
Centers for Disease Control and Prevention. (2002). Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR, 51 (No. RR-16):1-45.
Evans MW, Jr., Ramcharan M, Floyd R, Globe G, Ndetan H, Williams R, et al. A proposed protocol for hand and table sanitizing in chiropractic clinics and education institutions. J Chiropr Med. 2009 Mar;8(1):38-47.
• The Doctor of Chiropractic’s recommended course of action, and the nature of any recommended examination procedure, diagnostic test and/or treatment intervention
• Discussion of reasonable alternatives to the proposed course of action (regardless of their cost or the extent to which these options are covered by health insurance)
• The benefits, material risks and options, related to the recommended course of action.
• An assessment that the patient reasonably understands the discussion and is legally and mentally competent to make the decision
• The patient’s voluntary acceptance of the proposed course of action
In cases where the patient is a minor, or is legally or mentally incompetent, the patient’s parent, legal guardian or conservator must provide the consent. In instances where a language barrier exists between the doctor and patient, then informed consent should be given in the presence of a family member or other translator who demonstrates a reasonable proficiency to communicate relevant information between the patient and the doctor.
The informed consent process should be tailored to the individual patient. If a patient has any unique risk factors that might make that patient considerably more likely to experience significant complications from the proposed course of action, or make the patient considerably less likely to benefit from the proposed treatment, these issues should be discussed. The patient should also have an opportunity to ask questions to gain a better understanding of the procedure, test or treatment so that he/she can make an informed decision to proceed with, or to decline, a particular recommendation(s).
It is important that the Doctor of Chiropractic appropriately document in the patient’s health care record that this communication process took place, and whether the patient gave verbal and/or written consent to the recommendation(s). A written document signed by the patient in the presence of a witness may be useful to establish that an informed consent process was appropriately completed. However, the presence or absence of such a document may not—in itself—sufficiently demonstrate that the informed consent process was either adequate or inadequate. All informed refusals should also be documented.
Since the American Chiropractic Association (ACA) recognizes that there are varying legal standards for informed consent among different jurisdictions, it is recommended that Doctors of Chiropractic consult with their personal attorney, malpractice carrier, licensing board, state statutes, case law and CMS (Medicare) to determine the range and detail of the information required locally in an appropriate informed consent process.
By appropriately obtaining the informed consent of our patients, Doctors of Chiropractic will meet our ethical responsibilities to respect the autonomy of our patients. In addition, properly following a reasonable informed consent process might result in limiting the liability of the provider, since there would be an assumption of some risk on the part of the patient.
Reaffirmed by the ACA HOD, February 2010
High Resolution Infrared Imaging requires a high level of operator and interpreter competency and an adherence to established and consistent protocol.
The results of High Resolution Infrared Imaging must be properly correlated with a thorough history, an appropriate clinical examination, and other diagnostic studies/ tests as may be indicated by clinical necessity. In this setting, High Resolution Infrared Imaging may be an aid in establishing a differentiated diagnosis and in determining a prognosis. Guidelines for Infrared Imaging in Chiropractic Practice Infrared Imaging is a diagnostic procedure, which measures skin surface temperature distribution. This diagnostic imaging procedure is germane to chiropractic practice in cases where a physiologic test is required. High Resolution Infrared (HRI) Imaging is a useful procedure for the diagnosis of selected neurological and musculoskeletal conditions.
The treating doctor shall certify as to the medical necessity of the infrared imaging study based upon a diagnostic clinical question and the effect of the results on case management decisions. The referring doctor shall certify to the medical necessity by prescription.
HRI Imaging is of value in the diagnostic evaluation of patients when the clinical history suggests the presence of one of the following situations:
1. Early diagnosis and monitoring of reflex sympathetic dystrophy syndromes.
2. Evaluation of spinal nerve root fiber irritation and distal peripheral nerve fiber pathology for detection of sensory/ autonomic dysfunction.
3. To evaluate and monitor soft tissue injuries, including segmental dysfunction/ subluxation, sprain and myofascial conditions (strains and myofascial pain syndromes) not responding to clinical treatment.
4. To evaluate for the physiological significance of equivocal or minor anatomical findings seen on Myelogram, CT and/or MRI.
5. To evaluate for feigned disorders.
Because of the detailed knowledge, training, and skill level required, infrared imaging studies ordered, produced or interpreted by chiropractic physicians must be reviewed only by a licensed chiropractor who holds appropriate credentials with regard to knowledge, skill and experience in infrared imaging.
Only licensed chiropractors holding such credentials can claim sufficient competence to make valid judgments of comments regarding appropriateness, necessity, or accuracy of infrared imaging studies, and their relevance to chiropractic case management. (Ratified by the House of Delegates, June 1991; amended August 1999).
Resolved, that the American Chiropractic Association approves of the following list of policy and position statements relating to coding: Inappropriate X-Ray Bundling, Down-Coding and Bundling, CPT 97012 Mechanical Traction, Properly Appealing CCI Edits, Testing and Measurement Codes, Troubleshooting CCI Edit Denials, 2001 Radiology Code Clarifications, Physical Medicine Modalities, Tens Unit Professional Component, CPT 97010 Hot/Cold Packs, CPT 97124 Massage, and be it further
Resolved, that the American Chiropractic Association acknowledges that insurers should recognize the legitimacy and accuracy of these policy and position statements. [full text available on request or check the ACA website] (Ratified by the House of Delegates, August 2002).
Resolved, that the American Chiropractic Association acknowledges that insurers should recognize the legitimacy and accuracy of these policy and position statements, for the American Chiropractic Association has two representatives who sit on the American Medical Association CPT and RUC HCPAC Panels, and thus has accurate and precise knowledge of the intent of CPT codes and policies.
List of Policy/Position Statements Electrical Stimulation, Cox/Flexion Distraction, Surface Electromyography, Coding of X-rays and Other Imaging Studies. [full text available on request or check the ACA website] (ratified by the House of Delegates September 2004) Blue Cross & Blue Shield
Resolved, that the ACA consider the following to be key outcome measures of the success of the clinical integration process:
- The adoption of the Medicare RVRBS fee schedule with fee conversion factors equal to other physician providers.
- Reimbursement for the full scope of chiropractic practice established by state licensing law.
- Appointment of chiropractors to BCBS Credentialing, Quality Review and other policy-making panels. (Ratified by the House of Delegates, August 2002).
The ACA is opposed to the contractual exclusions of diagnosis and manipulation of subluxation as presently written into various insurance contracts. The ACA Insurance Committee is directed to pursue every conciliatory and/or legal means to alleviate these restrictive contract riders without compromise of cost, peer review, or physician responsibility to his patient. (Approved, February 1975).
Resolved, with dedicated leadership, our goal is to obtain the broadest insurance and managed care coverage possible for the full scope of chiropractic services, procedures and products doctors of chiropractic are trained to use through accredited chiropractic colleges and other recognized institutions. These services, procedures and products should be reflected in reimbursable insurance benefits that have parity to other providers who perform same, similar or like services.
ACA commits to insurance outreach within a broad chiropractic definition as a core business practice to: expand access, optimize coverage for patients, and to improve the reimbursement experience for all doctors of chiropractic.
While ACA recognizes a broad chiropractic definition and scope of practice, the ACA acknowledges it is the treating provider's right to practice as narrowly or as broadly as clinically indicated within their legal scope of practice. (Ratified by the House of Delegates, March 2004).
The American Chiropractic Association (ACA) takes a pre-emptive, direct action role to advocate and protect doctors of chiropractic (DC) and the patients they serve. This is executed through a wide range of highly focused operational strategies including: grassroots lobbying on Capital Hill, direct outreach with payers and employers, and lawsuits, as needed, against various regulatory agencies/entities to obtain fair policy and reimbursement.
ACA's Long-Range Plan identifies fair reimbursement policy as a primary goal and a necessary vision for the chiropractic profession. Reimbursement policy is broadly defined to incorporate differences in philosophical beliefs, special interests, educational backgrounds, and varying state scope of practice for doctors of chiropractic nationally.
With dedicated leadership, our goal is to obtain the broadest insurance and managed care coverage possible for the full scope of chiropractic services, procedures and products doctors of chiropractic are trained to use through accredited chiropractic colleges and other recognized institutions. These services, procedures and products should be reflected in reimbursable insurance benefits that have parity to other providers who perform same, similar or like services.
Coverage Terms and Benefit Requirements
The following are common topics of discussion and negotiation around insurance coverage and benefits:
- Physician Level Status
- Primary Care Provider Role
- Full Scope of Services
- Direct Access
- Care Definitions Based on the Chiropractic Model of Care
- Treatment Based on Medical Necessity
- Parity in Pay
- Clinical Documentation Requirements
- Fee-for-Service or Fair Market Value Arrangement
- Current Procedure Terminology Billing Code Definition
- Elimination of Inaccurate Bundling and Down-Coding Edits
- Fair Claim Practices
- Regulatory Compliance in Claim Handling
- Timely Payments
- Administrative Streamlining of Reports and Data
- Payment on Demand (billing vs. appeal process)No Limits or Caps Impacting the Provision of Quality of Care
- Medical Review Practices that are Intimidation Free
- Biased or Negative Mind-Set Against the Profession
- Research Methodology Based on Chiropractic Principals
- Wellness Model
ACA commits to insurance outreach within a broad chiropractic definition as a core business practice to: expand access, optimize coverage for patients, and to improve the reimbursement experience for all doctors of chiropractic.
While ACA recognizes a broad chiropractic definition and scope of practice, the ACA acknowledges it is the treating provider's right to practice as narrowly or as broadly as clinically indicated within their legal scope of practice. (Ratified by the House of Delegates, September 2004).
Discount "Benefit" Plans
Resolved, that the ACA is on record in opposition to these various discount schemes which are proposed to the public and the profession as "benefit" programs for Chiropractic, which result in the employer, the HMO or the insurance companies having no financial outlay for these services they purport to provide and which provide for doctors to discount their services and enrollees to pay for those discounted services out of pocket, and, be it further
Resolved, that the ACA will notify these insurers that are promoting these discount Chiropractic services as real Chiropractic benefit plans to include Chiropractic Health Care in their core benefit package as described in ACA's mission statement, legislative agenda, and long-range plan. (Ratified by the House of Delegates, March 2000).
A consumer's freedom of choice to select among all state-licensed health care providers is an essential attribute of any effective and responsive national health goal. Currently, the right to choose chiropractic treatment is currently protected under the laws of 45 states. These laws have come under attack as mandating additional benefit and therefore additional costs. These laws, in fact, only provide the basis for the provision of alternative rather than additional services.
Resolved that the ACA adopt the following Position Paper on State Insurance Equality:
There is currently underway an effort by certain vested interests in the insurance industry and by certain others (United States Chamber of Commerce and many of its constituent and component state and local chambers) to repeal "state mandated" insurance benefits. Such efforts are either self-serving (carrying profit motives in the instances of the former) or based on inaccurate information in the latter. Led by Sen. Edward Kennedy (D-MA), legislation has been introduced in the United States Congress to force small businesses to provide health care coverage for any employees who work more than 17.5 hours per week and to pay the premiums for such coverage (minus deductibles and co-insurance). Driven by this legislation, the insurance industry and others have mounted opposition to its passage based on the argument that such "additional" coverage as mental health, podiatry, optometry, nurse midwifery, chiropractic services and drug-dependency programs (plus almost 700 others) could only be included at a confiscatory cost to small businesses. Many of these services are now "mandated" by certain state laws.
To understand the confusion created, one must see the difference between what is an add-on service (costing additional monies/ premiums) and what is a displacement service (the same covered service but one possibly being provided by an alternative, state-authorized health care provider).
State laws that seem to mandate certain health care services often do not do so; rather, they "mandate" non-discrimination. In other words, they mandate that a privileged economic position -- a competitive advantage -- will not be given to one class of state authorized health provider over another. Such laws paraphrased say this: "Any health benefit covered under an insurance policy that reimburses for treatment of a particular type of health condition when provided by one class of authorized health care practitioner must be reimbursable when provided by any health care practitioner licensed to provide such service." The law does not even mention any practitioners or any health condition. It is anathema, however, to any group, which hopes to hold an exclusive economic "right" to the entire health care field.
To state the practical impact of a state law such as quoted above, we would see that if an insurance policy already covers the examination of the eyes and the provision of corrective lenses when done by an ophthalmologist, then it must pay for these same procedures when performed by an optometrist (both ophthalmologists and optometrists are licensed by the state to provide these services). This nondiscrimination statute does not cost any business (or an insurance company) additional money since going to the optometrist for these services displaces the need to seek the same services from the ophthalmologist (M.D); in fact, the net cost may be lower because of the competition involved.
If an insurance policy pays for treatment of back conditions by an osteopath or a competing orthopedic surgeon, then it must pay for the same health condition when provided by a chiropractic physician (under the law). A different service is not being provided; only a different health care provider is being reimbursed. The competition is obvious, as are the resulting lower net costs, including less cost to the patient, less cost to the employer, less loss of time on the job to the employee and less pain to the employee. The net result is a cost saving rather than an added financial burden. The costs of health care are burgeoning, taking an ever-larger portion of the nation's gross national product. Now is the time to look more aggressively at the savings, which can be realized by the use of alternative, reliable (chiropractic care has the lowest incidence of adverse side effects of any known medical modality) and more economical health care services. Each time the argument is made against "state mandated" health care benefits, the listener should ask the question, "is this benefit reimbursed if it is provided by a certain privileged group of practitioners or is it not reimbursable under any conditions?" If the answer reveals that competition exists in the system, then, like the United States Congress long ago stated competition will provide us with the most efficient, quality oriented and lowest cost health care anywhere. (Ratified by the House of Delegates, June 1990).
Resolved, that the ACA work for the inclusion of chiropractic in all public and private health programs by name, when possible. (Ratified by the House of Delegates, June 1975).
The position of the American Chiropractic Association is as originally established and annually reaffirmed that the individual doctor of chiropractic (chiropractic physician) has the privilege and the obligation to practice in accordance with his education received in a recognized college of chiropractic and in accordance with the statutes of the state in which he practices.
The American Chiropractic Association extends an open invitation to meet with any other chiropractic group or organization to discuss, in accord with the statements above, those other items upon which they feel compelled to negotiate agreement in order to achieve a unified profession.
The American Chiropractic Association will continue its program for greater recognition and acceptance of the profession to the ultimate benefit of health service to the public and doctors of chiropractic (chiropractic physicians) everywhere.
The American Chiropractic Association will continue to work with and aid all state associations to develop their individual programs.
The American Chiropractic Association believes this is the best course for professional progress and invites all doctors of chiropractic (chiropractic physicians) to unite in this effort. (Adopted by the House of Delegates, June 1967,reaffirmed, June 1985, July 1993, July 1994, June 1995, May 1996, June 1997, June 1998, reaffirmed and amended August 1999, reaffirmed September 2000, September 2001, August 2002, September 2003 and September 2004).
Stephen M. Perle, DC, MS. Ethical Approaches to New Diagnostic Methods and Treatments
…taping over and around muscles in order to assist and give support or to prevent over-contraction. The first technique gives the practitioner the opportunity to actually give support while maintaining full range of motion, enabling the individual to participate in physical activity with functional assistance. The second technique helps prevent overuse or over-contraction and helps provide facilitation of lymph flow 24 hours per day.1
Kinesiology Taping is said to offer patient benefit by increasing or inhibiting muscle tonus by providing mechanical compression, or by the diversion of stress through the tissues utilizing parallel elastic fibers. Although commonly used during acute stage of injury for controlling lymphatic flow, conditions creating macro or micro lymphedema can be addressed.
For reporting this service, CPT offers the following:
Because Kinesio® tape is a supply, its application is included in the time spent in direct contact with a patient to provide either re-education of a muscle and movement or to stabilize one body area to enable improved strength or range of motion. The application of tape is usually performed in conjunction with educating the patient on various functional movement patterns. The tape is applied based on the patient's specific patterns of weakness or strength. The tape is left in place after instruction related to movements designed for improving strength, range, and coordination is provided and documented.
However, if the purpose of the taping is immobilization, then the strapping codes may be appropriate as those codes describe the use of a strap or other reinforced material applied post-fracture or other injury to immobilize the joint. If the taping is performed to facilitate movement by providing support, and the tape is applied specifically to enable less painful use of the joint and greater function (i.e., restricting in some movement, facilitating others), application of tape in this manner is typically part of neuromuscular re-education (97112) or therapeutic exercise (97110), depending on the intent and the outcome desired. This includes application of Kinesio® tape or McConnell taping techniques.2
As such, when applying Kinesiology Taping to a patient in conjunction with another therapy, the Kinesiology Taping service should not be separately reported. It is not appropriate to code 97110 or 97112, etc. if kinesiology taping is the only work performed. The only appropriate code to report, in addition to the therapy service rendered, would be the supply code for the tape itself, either A4450 Tape, non-waterproof, per 18 sq. inch or A4452 Tape, waterproof, per 18 sq. inch.
2 March 2012 CPT Assistant
(Ratified by the House of Delegates, September 2012)
Resolved, that the ACA must develop the background research and statistics relative to the quality and effectiveness of care in managed care programs that eliminate or restrict the use of chiropractic care verses those that allow direct access. Be it further
Resolved, that the ACA must aggressively pursue the implementation of direct access as an essential model in the managed care industry. Be it further
Resolved, that the ACA should strive to create a general understanding in the minds of all health professions, legislators, employers, payers and the general public the devastating impact medical gatekeepers have on the ability of patients to access doctors of chiropractic. Be it further
Resolved, that the ACA should develop data, strategies and methods of implementation to ensure direct access as a universal managed care model. Be it further
Resolved, that the ACA should enlist the help of interested parties, including consumers, legislators, employers, payers and health care providers in pursuing direct access. (Ratified by the House of Delegates June 1998).
Resolved, that the ACA actively seek to have doctors of chiropractic included on managed care organization panels on a direct access basis, and on managed care organization's medical advisory committees, medical credentialing committees, etc. This will ensure chiropractic availability for the health consumer. (Ratified by the House of Delegates August 1999).
Resolved, that the ACA vehemently opposes these harmful and discriminatory practices, including but not limited to: limiting full scope of practice, inappropriate CPT applications and reimbursement policies, use of discount/affinity programs, restrictive limits of care, and improper utilization review. Be it further resolved that ACA staff and leadership are directed to communicate our concerns to the profession; obtain detailed data on these abuses; develop and implement a plan to halt these unfair practices; and give a status report in August 2002 and at each subsequent House of Delegates meeting. (Ratified by the House of Delegates, March 2002).
Resolved, that the American Chiropractic Association House of Delegates adopt the following policy position:
ACA opposes any attempt to impose artificial educational requirements beyond those established by colleges accredited by the Council on Chiropractic Education and state licensing boards, as criterion for credentialing as a provider in any managed care or third party payer plan. Such artificial educational requirements serve as an improper restraint on the ability of a licensed doctor of chiropractic to freely practice his profession. (Ratified by the House of Delegates, June 1998).
Resolved, that ACA opposes any limitations by public and private insurers including managed care networks, as it relates to chiropractic coverage, benefits, and reimbursement that negatively impact the clinical decision making process and the quality of care proposed or administered to a chiropractic patient. These limitations may include but are not limited to the following actions taken by payers, their agents, employees, consultants, or business partners, to intimidate, dissuade or present a financial hardship for either the patient in obtaining, or the provider in rendering quality care.
Discriminatory reimbursement practices which are not equitable or the same as for other providers rendering the same or like services.
Benefit language or claim handling actions that direct a patient away from their choice of provider to another discipline that cannot provide a unique chiropractic service or is not adequately educated and trained, skill tested, and licensed to perform the chiropractic care.
Presenting obstacles in the way of access, coverage or benefit structure that eliminate options for the patient to choose a model of healthcare that is non-invasive, holistic and wellness based in lieu of the traditional surgical/pharmaceutical model of healthcare.
Treatment values, schedules, bundling of services, global or per diem fees, capped benefits and unfair conversion factors applied to treatment codes that do not provide fair market value for the type of service(s) provided but that are necessary to effect quality care.
Co-sharing terms that negate the insurance paid benefit or which exceed the benefit allowance and place the majority (50% or above) or entire financial burden on the patient for payment.
Multiple co-payments applied to a single episode or day of care provided by a provider or providers in the provision of quality care.
Any financial arrangement that promotes improper use of healthcare services, including under or over use of necessary care.
Contract terms, benefits or coverage that change the status of a doctor of chiropractic to a lower (non-physician) or higher (specialist) level for the purposes of limiting and/or excluding insurance reimbursement for the patient.
Any hybrid system of reimbursement system that has no direct relationship to services rendered.
Any reimbursement of chiropractors, which does not take into consideration methods to determine proper and reasonable compensation, such as RBRVS and conversion factors, raises the potential of inadequate quality of care, which may result in harm to the patient.
Any other coverage terms, benefit determination, practice or policy, contract revision or change that shifts financial responsibility to the patient or provider that is not totally disclosed and accepted in writing and for which a premium adjustment is made to reflect a lower amount of benefits.
- Appropriate use of premium dollars as it applies to the provision of quality care in any insurance plan as referenced above
- Utilization Review and other accreditation criteria to address limitations on care that negatively impact quality of care.
- Appropriate coverage and options for healthcare models that allow patient choice of care.
- Elimination of inappropriate shifting of paid insurance benefits to patient paid benefits without written and approved notice and premium adjustment.
- Appropriate classification of providers for benefit determinations.
- Fair market value reimbursement for necessary services the provider must render to the patient within a quality of care framework.
ACA is strongly opposed to any decision by a payer, employer or managed care entity that eliminates and / or diminishes reimbursable chiropractic coverage especially those that compromise quality patient care. (Ratified by the House of Delegates, March 2003).
Resolved, that in response to ACA member concerns regarding the requirement of high levels of malpractice insurance required by managed care organizations and the substantial cost incurred by ACA members to meet these inflated requirements, the ACA makes the following statement:
1. For the protection of the patient and the doctor of chiropractic, doctors of chiropractic should purchase and be covered by malpractice liability insurance;
2. The ACA calls upon all managed care organizations to justify to the doctor of chiropractic the necessity of their required levels of malpractice liability. (Ratified by the House of Delegates, June 1998).
The use of specialty board certification as a criterion for inclusion in managed care would discriminate against, create an artificial barrier to, and preclude the use of the vast majority of quality-based and qualified, doctors or chiropractic.
It is the policy of the American Chiropractic Association that specialty board certification should not be a criterion for membership as a provider in any managed care or third party payer's plan. The American Chiropractic Association opposes any attempt to impose any artificial standard of qualification as a criterion for credentialing participation by DC's in health care plans. (Ratified by the House of Delegates, June 1997).
Resolved, that in keeping with current policy of the American Chiropractic Association that specialty councils and their members adhere to the policy that specialty board certification not be a criterion for membership as a provider in any managed care or third party payer plans and that the councils promote the use of all doctors of chiropractic in all managed care and third party payer claims. (Ratified by the House of Delegates, August 1999).
Resolved, that the HOD, in order to develop an improved platform of managed care, adopts the Matrix and instructs staff and leadership to seek out and promote those networks that agree with these responsibilities, as evident in their policies and operational procedures.
Professional Responsibility Matrix
The American Chiropractic Association (ACA) and chiropractic networks have common interests in finding ways to cooperate with one another. Those interests center on the value in selecting chiropractic care and the patient's ability to obtain direct access to a doctor of chiropractic and quality care within payer plans.
To further the market value initiative, a forum has been established for the ACA and chiropractic networks to discuss issues of common interest and seek the greatest good for the patient. It is understood there are various market factors for both the networks and plan providers that need to be fully assessed as this collaborative initiative moves forward and that each group needs to assist the other in that regard. The following matrix identifies major priorities and serves as a roadmap to an improved business relationship to benefit the chiropractic patient and the advancement of chiropractic in insurance paid plans. This is a living document to represent the beginning of a process to be improved upon over time. It is fully understood that market forces and membership concerns may be at cross purposes at times but more good is gained in collaborative efforts than adversity. (Ratified by the House of Delegates August 2002) [Full text available on request]
Resolved, that the ACA considers the use of manipulative adjustments by persons with less training than that required in the core curriculum of approved chiropractic, or osteopathic educational institutions to be a danger to the public health, safety and welfare. (Ratified by the House of Delegates, June 1984).
WHEREAS, The American Chiropractic Association recognizes that manipulation under anesthesia has a long established history, supported by many years of clinical research, as an accepted established procedure within and outside the profession; and
WHEREAS, The American Chiropractic Association recognizes that each state has a legislatively established and statutorily authorized regulatory agency for the specific purposes of regulating the practice of chiropractic pursuant to each state’s enabling legislation for such regulatory agencies; and
WHEREAS, The American Chiropractic Association supports each state’s right and privilege to establish separate and autonomous scopes of practice, practice parameters and regulatory agencies for the practice of chiropractic. Therefore be it
RESOLVED, that the American Chiropractic Association recognize and support that Manipulation Under Anesthesia has a well established clinical history within the chiropractic profession, accredited chiropractic academic institutions, chiropractic clinical research, and chiropractic private practice sector in both hospital and ambulatory surgical center settings, and moreover that MUA procedures are appropriate in a selected patient population pursuant to established clinical guidelines promulgated by established chiropractic authoritative sources including accredited academic institutions’ MUA training programs, state regulatory agencies rules and regulations, and qualified instructors of MUA procedures who teach the MUA courses under the auspices of accredited academic institutions.
The ACA position refers to those appropriate examinations, therapeutic substances, and treatment procedures that are used by licensed practitioners to diagnose and treat patients with a specific condition.
Implied is the fact that the condition be a recognized one and that the examinations, tests, therapeutic substances, and treatment procedures used are based on scientific principles and studies, are generally accepted by the profession as being needed, essential, and appropriate to properly diagnose and treat patients with the particular condition. Quality and quantity of examination and therapeutic procedures must be within the norms and/or criteria established by the profession as a whole for such a condition.
Implied also is the fact that there must be documentation in the medical records and/or reports to substantiate the need for the services rendered. (Approved, July 1975).
Resolved, that medical necessity should be based on a standard that is tied to principles of professional practice as accepted by the particular field of professional practice. Health plans should be prohibited from interfering with medically necessary care as determined by the treating health care provider acting within the scope of his or her practice. The patients of all health care providers should have the right to receive medically necessary care as determined by their practitioners. This position should also be included in the list of patient protections in any managed care legislation that is passed by Congress. (Ratified by the House of Delegates, August 1999).
Resolved, that these policies and definitions do not represent, nor are they intended to be, Standards of Care. And, be it further
Resolved, that these policies and definitions do not supersede any established governmental laws, official administrative regulations or judicial rulings.
Resolved, that these policies are developed with a general reference to all health care providers. Therefore, all references to medicine or medical and physician are universal and interchangeable with doctor of chiropractic (chiropractic physician, chiropractor) respectively. (The text printed above is an abstract of a policy statement ratified by the House of Delegates, August 1999. A copy of the complete policy statement can be obtained from ACA Headquarters).
Resolved, that efforts be made by the ACA, when and as appropriate, to amend the involved clause in the Medicare law to strike "to correct a subluxation" and insert "for treatment of subluxations and symptoms referable to same". (Ratified by the House of Delegates, June 1983).
The Physician Payment Review Commission has adopted the policy of eliminating "specialty differentials" in the Medicare fee schedule, and the ACA testified before the PPRC in support of the elimination of Medicare specialty differentials.
The ACA believes doctors of chiropractic are either equally or better trained than M.D.s, D.O.s, or P.T.s in performing manipulative services. The PPRC has recognized the distinction between chiropractic and medical manipulation in its 1990 Report to Congress. The PPRC has proposed to institute this recognition through the creation of "a separate budget neutral fee schedule that incorporates a geographic adjustor . . . constructed for the single chiropractic service covered by Medicare."
Based on the recognition that chiropractic manipulation is distinct from any other manipulation, the Medicare system has no basis for continuing to deny the provision of chiropractic services to Medicare HMO patients. Resolved, that any fee schedule should reimburse chiropractic manipulation at a rate equal to or higher than, but in no instances less than, the rate paid for M.D.s, D.O.s or P.T.s manipulative services. (Ratified by the House of Delegates, June 1990). Health Subcommittee Recommendations
A joint statement of the American Chiropractic Association and the International Chiropractors Association submitted to the Subcommittee on Health, Committee on Ways and Means, House of Representatives on Medicare, concluded that if the ACA/ICA recommendations are adopted, the following legislative changes would result:
(1) The authorization of the payment to beneficiaries for x-rays performed or required by doctors of chiropractic and for physical examination (and related routine laboratory tests) for the purpose of determining subluxations and/or referral to other health care providers;
(2) The authorization of doctors of chiropractic to demonstrate the existence of spinal subluxations by "other chiropractic procedures", as well as by x-ray, therapy avoiding unnecessary radiation to patients; and
(3) The authorization for doctors of chiropractic to interpret their x-rays. (Submitted September 1975 and in similar language in June 1974).
Resolved, that ACA will continue to be in contact with HCFA for clarification of why the chiropractic consultants are not used in the review process, why the GA modifier is being ignored during the prepayment review, and why the denial rate is so high for chiropractic claims, even for a new patient. (Ratified by the House of Delegates, September 2000).
It is not the intention of ACA to provide legal or clinical recommendations, however, we feel an obligation as the world's largest professional association representing doctors of chiropractic, to comment on this practice arrangement and the potential impact it may have on the quality of patient care.
There are instances of mobile services and use of diagnostics by doctors of chiropractic that are fully within their scope of practice and are medically indicated as documented by the treating provider. The ACA supports the profession acting within their state law who are trained to perform and assess these services as clinically indicated.
We caution the chiropractic community when entering into a rental or lease agreement that is or could be perceived as placing financial gain over the best interests of the patient. The ACA Code of Ethics Policy clearly advises:
|"As primary obligation of the doctor of chiropractic the exercise of clinical judgment and practice [is] solely for the patient's benefit. In the view of this association, the receipt of any form of remuneration for a patient referral runs directly counter to this primary obligation and tends to adversely impact upon the relationship between the chiropractor and patient."|
Ask Yourself These Questions
- Does the patient need the services(s) and can I clearly document the medical necessity for each and every test?
- Do I as the treating provider have an obligation to determine the extent of all testing and services?
- Am I being induced to order tests from the mobile diagnostic facility?
- Does every test or combination of tests yield an outcome that is beneficial for the patient?
- Do I know if services are being performed or interpreted by a certified, licensed professional with clinical education and knowledge of the tests and analysis according to state regulations? And, are the qualifications and licensure of the person writing the report available to you and are they state compliant?
- Do I have a clear line of authority and supervision over the technician performing the testing?
- What assurances do I have that the equipment is in good operational order, is reliable, and may not present harm to the patient?
- Does the test in question meet "generally accepted" requirements relative to its purported use?
- Am I liable for any harm to the patient?
- Have I received any kickbacks, gifts or funds for patient referrals?
- Have I been advised to bill for the technical component on equipment that I do not own?
- Have I personally analyzed the test report(s) to determine they are patient specific and give me a clear picture of the patient results?
- Have I ordered tests or referred the patient for services that are for my financial gain and may not be in the best interest of the patient?
- Are there any state laws that may influence my decision or that require specific compliance requirements?
- Have I spoken with my attorney or malpractice carrier about all potential liabilities?
Your thoughtful consideration on the full ramifications of a rental and/or lease agreement on electro-diagnostic testing or other patient referral services will protect you and the image of the chiropractic profession. More information can be found at:
ACA Ethics Policy Addendum
1701 Clarendon Blvd., Suite 200, Arlington, VA 22209. Phone 703 276-8800. Request the Insurance Relations Department for any other information. (Ratified by the House of Delegates, September 2004).
The goal of this policy is to provide general education as opposed to specific legal or practice advice. It is incumbent upon each doctor of chiropractic to determine relevant state or federal laws, local board regulations and/or association recommendations that may be pre-emptive.
Background: The ACA fields an increasing volume of calls from doctors of chiropractic as to the advisability of entering into a MDP, and who also seek more detailed information on its acceptance, structure and operating philosophies. At the same time, ACA receives complaints from payers that certain arrangements appear to emphasize financial gain for providers rather than clinical appropriateness and the best interests of patients. With respect to providing education to both the chiropractic and insurance professions, ACA established a Fraud Sub-Committee under the Insurance and Managed Care Committee to research and provide commentary on this topic.
This committee includes doctors in private practice from across the country, chiropractic leadership, insurance industry representatives, legal counsel, and consultants who have experience in the health care field. The committee recommends that doctors thoroughly review the following issues before entering into, being an employee of, or owning (in part or in total), a Multi-Discipline Practice.
The recommendations provided are not all-inclusive, but are intended to provide thoughtful guidance prior to engagement within a Multi-Disciple Practice. The mission is to provide world class integrative care to the whole person.
Multi-Discipline Practices: ACA RECOMMENDATIONS
It is recommended that doctors of chiropractic / chiropractic physicians maintain a current license in good standing in the state in which they practice, and comply with the full letter and intent of that state's practice statute. All care or services rendered by a doctor of chiropractic must fall under their applicable state licensure. The practicing chiropractor cannot be delegated by another health care professional to perform procedures not within their own licensure.
Seek Expert Opinion and Counsel:
As is the case in any new business venture, one should seek expert opinion and counsel. The ACA may be contacted for information or the National Association of Chiropractic Attorneys (NACA) as one source of possible legal counsel. Consideration must be given to the several complex legal issues to creating any business venture with an additional level of Federal and State compliance concerns for the health care professional. Thus professionals involved with the formation of an MDP should seek legal advice from an expert knowledgeable in the applicable laws of the jurisdiction considered for the practice. The bullet list appearing below is not intended to be exhaustive, however it will provide guidance in several matters of concern for:
- All licensed healthcare providers are held to administrative, civil and criminal law considerations. In addition, state and federal law impacts compliance, formation, ownership structure and operational issues and may present certain complexities requiring the advice of an attorney specializing in professional limited liability (PLLC), Partnership (PLLP) and/or other arrangements.
- Legal concerns regarding federal and state anti-kickback laws. These are enforced for the most part by civil versus criminal sanctions. This requires a comprehensive review and careful consideration of "safe harbor" provisions of the Civil Monetary Penalty Act (42 U.S.C. 1320a-7a).
- Legal prohibitions against self-referral for some healthcare services, or "Stark Laws" (42 U.S.C. 1395 nn) are enforced through civil sanctions and relate to the provision of certain designated health care services. Mini-Stark laws may also exist at the state level and should be considered in any MDP analysis.
- The Internal Revenue Service (IRS) may also have specific compliance standards in the reporting of MDP revenue, investment gains and/or other financial situations.
- Consultation with a malpractice insurance carrier is advisable to maintain complete coverage for the entities’ professional staff.
- The Department of Health and Human Service Office of Inspector General posts an internet document‘Compliance Program for Individual and Small Group Physician Practices’ (65 Fed. Reg. 59434, Oct. 5, 2000) found at http://oig.hhs.gov/authorties/docs/physican.pdf which should be evaluated.
- Clinical documentation and billing must clearly identify the provider’s specialty and specific services rendered by each provider. Legal ramifications may occur if one provider bills under another providers license thereby achieving a greater scope of practice or reimbursement fee schedule.
Other Considerations and Questions to Answer
- Hiring Licensed and Unlicensed Providers/Professionals: Are you providing oversight and supervision for licensed and unlicensed providers/professionals exclusively for services included within the licensure for a doctor of chiropractic in your state? You should not provide oversight and supervision for licensed and unlicensed providers/professionals for services that are not included within the licensure for a doctor of chiropractic. Remember you are responsible for all acts of licensed and unlicensed employees and staff in your employ.
- Patient Supervision: Are you available and on-site with sufficient frequency and predictability to oversee patient care provided by all licensed and unlicensed employees and staff? Is continuity of patient care a major priority? In the event of an emergency, do you have sufficient oversight to direct employees and staff to appropriate action that protects patient safety and the best possible clinical outcome? Are there written compliance procedures in place and are they reviewed periodically for safety and confidentiality compliance? Remember that absentee ownership may create unnecessary risk and liability.
- Patient Referrals: If a patient is referred to you within a MDP owned by a physician other than a doctor of chiropractic are there delineated criteria for referring patients that may benefit from your specialized care?
Is the referring physician or provider familiar with chiropractic principles of care and fluent in your evaluation and diagnosis protocols, treatment and techniques, therapies or related services? Is the referred patient aware of the same principles and are they educated as to the expected results?
Is there an expected clinical outcome that is anticipated by making a referral either within or outside the MDP? Is there a plan of care and an expected time frame for results recorded and reported between providers and the patient?
Is there an adequate level of clinical documentation to support the referral and all care and treatment? What kind of written communication will the referring provider expect of the doctor of chiropractic, and do the DC's clinical records provide enough objective evidence to continue care?
Have steps been taken to avoid "automatic" referrals that lack clear and convincing evidence of the need for specialized care?
- Coding and Billing: Are all codes and billing procedures consistent with CPT definitions and policies, and do they not duplicate services the patient received prior to or during concurrent care at the MDP facility?
Incident-to services: Incident to billing procedures can vary from carrier to carrier, and may be state specific. Always check with the particular plan to assess whether billing a chiropractic service as "incident to" another physician's service is authorized.
Are evaluation and management services and/or consultation services appropriate and properly documented? Are the billed procedures separately identifiable? Do these services require significant patient time, assessment, cognitive skills and patient care management over and above existing recorded information on the patient? Under what situation does a patient require complex and/or multiple complex assessments by the same or different provider in the MDP facility?
Are your services billed under your tax ID number and not under a higher level or specialty ID number? This is prevented by having the proper NPI and Taxonomy Numbers of each provider within a MDP. These numbers clearly state. The specific provider of each billed service.
Remember, coding abuse-especially for frequently performed E/M services or for frequently billed complex services that are not clinically supported-is a red flag for investigation. Financial recovery, penalties and even license sanctioning can be an outcome of intentional coding irregularities. An argument for determination of intentional abuse is easily made when claims data shows an established business pattern.
There is an assortment of imperative considerations one must evaluate prior, to involvement within a Multidisciplinary practice. Ultimately the relationship is intended to foster an innovative atmosphere to promote patient-focused health care in compliance with lawful and ethical practice. ACA has provided this information to help prevent undesirable situations that could inadvertently occur when there is inadequate analysis and preparation for new and emerging business collaborations. Related commentary may be found in ACA's Code of Ethics found at www.acatoday.org.
For more information please contact the ACA Insurance Relations Department at (703) 276-8800 or submit a written inquiry to the ACA IMC Fraud Sub-Committee at:
American Chiropractic Association
1701 Clarendon Blvd., Suite 200
Arlington, VA 22209
(Ratified by the House of Delegates (HOD), March 2005. Modified by the HOD, February 2012. Updated by the HOD, September 2012.)
Osteoporosis is a silent insidious disease process, primarily of the post menopausal female, which if undiagnosed or untreated may lead to severe crippling and deformity.
Its initial diagnosis may often be made by the chiropractic physician in sufficient time to arrest or hinder its progress.
Its prevention is enhanced by timely and appropriate dietary recommendations, consideration of hormone replacement therapy if indicated, and common sense exercise.
Its cure has yet to be identified, if by cure, it is meant the return to normal architectural strength and integrity of bone. (Ratified by the House of Delegates, June 1986).
The ACA recognizes that financial interests in such facilities by referring health care providers may constitute an inherent conflict interest between the financial interest of the referring provider and the health interest of the patient.
The ACA cautions its members that it regards financial conflicts of interest, which may increase the patient's overall health care costs to be unacceptable. (Ratified by the House of Delegates, May 1992).
Sickness and injury in America account for more than 500,000 days lost from work each year (estimated by Bureau of Labor Statistics) at a cost to the country of over 21 billion dollars (estimated by National Safety Council). It is the best interest of both the employer and the worker that sickness absence be kept at the lowest level. Economists agree that better productivity per hour will be an essential feature of our nation's effort to return to a stable economy. Less absence from work would contribute to the American Chiropractic Association's effort to control cost of health care. Chiropractors are responsible for the amount of time an employee should be allowed to be away from work for the purpose rehabilitation. Resolved, that the American Chiropractic Association continues to encourage chiropractors everywhere to have their patients return to work at the earliest date compatible with health and safety. (Ratified by the House of Delegates, June 1982).
Implementation of medical review for all claims or classes of providers, or conditions treated by certain providers is objectionable and may not be a prudent use of premium dollars. It can unnecessarily lengthen the claim settlement time for the insured patient, and burdens the provider with added administrative expenses. Furthermore, when medical review is provided in a discriminatory fashion, it may cause additional expense to the insurer or managed care organization.
ACA believes it is necessary to have certain requirements in place when chiropractic policy and claim decisions are made to assure the claim is fairly evaluated by those who are knowledgeable and educated in current chiropractic science.
These guidelines would apply to any payer, insurer, MCO or any health plan, medical coverage or fund including its claim management, adjusters, medical review staff, professional consultants, utilization reviewers or other agents or vendors of the insurer or company who develop medical review policy and make medical review determinations, especially as they pertain to chiropractic care claims.
In order to have true review accountability by chiropractic consultants, there needs to be independence of the consultant. This can be accomplished when the consultant is chosen from a panel of volunteers independent from the patient or insurance company. The fee for the review would be paid by the person or company requesting the examination. If an insurance company picks from an established list of consultants and then pays to have the review performed, the selection process would be contrary to independence and/or objectivity.
The full test of this policy including, operational philosophy, compliance with state laws and regulations, consultant and independent medical exam selection criteria, data integrity, treatment provisions, clinical documentation, appeals process, training and referrals for medical review, fraud, communications and coding is available upon request. (Ratified by the House of Delegates September 2001)
The ACA affirms that pediatric chiropractic care, when administered properly, is effective, safe and gentle, and
The ACA affirms that chiropractic care for children is appropriate for many musculoskeletal as well as non-musculoskeletal conditions of childhood, and
The ACA affirms that chiropractic plays an important role for children in health and wellness promotion as well as illness prevention, and
The ACA recognizes that the Doctor of Chiropractic is an important member of the integrative pediatric health care team and encourages Doctors of Chiropractic to work with pediatric practitioners from other fields of healthcare when appropriate to maximize each child’s health and wellbeing.
*References available upon request.
Because accredited chiropractic colleges which are approved by the Council on Chiropractic Education require proficiency in physical examination procedures, including the areas of cardiovascular, respiratory, renal, gastrointestinal, neurological, orthopedic and laboratory diagnostic procedures, the ACA reaffirms its position of support regarding the performance of physical examinations which require the examiner to diagnose the presence or absence of health conditions and illnesses. An ACA staff task force will be initiated to prepare a comprehensive report on the educational requirements of a doctor of chiropractic as they relate directly to the right to conduct physical examinations. Further, the task force will develop model legislation for use by state chiropractic associations, which would protect the rights of a doctor of chiropractic to perform physical examinations. The ACA will serve as a clearinghouse for information regarding programs and organizations that currently utilize doctors of chiropractic to conduct physical examinations including legal and attorney general opinions and other materials. (Ratified by the House of Delegates, June 1997).
Resolved, that DCs be recognized as "physicians," federally, as opposed to any other "health care provider" status. (Ratified by the House of Delegates, July 1995, reaffirmed August 1999)
Resolved, that ACA draft model legislation to be made available to state associations to maintain and expand DCs as "physicians." (Ratified by the House of Delegates, July 1995 reaffirmed August 1999)).
Resolved, that the ACA request the Council on Chiropractic Education join the American Chiropractic Association in a petition to the Federation of Chiropractic Licensing Boards seeking a uniform approval procedure for continuing education and convention programs conducted under the auspices of the CCE and its member institutions for the purpose of license renewal. (Ratified by the House of Delegates, July 1974).
The ACA supports the position of the Council on Chiropractic Education on continuing education which states in part, "The Council holds that only academic institutions can and should conduct postgraduate courses and deplores the itinerant, privately conducted programs generally presented for private gain." The ACA subscribes to and recommends the Educational Standard for Postgraduate (Continuing) Education of the Council on Chiropractic Education. (Approved, July 1975).
Resolved, that the ACA encourages and recommends its members to obtain consistent continuing education which may include self-study. (Ratified by the House of Delegates, June 1985).
Continuing Education, In-Person Classroom Study
Resolved, the American Chiropractic Association supports in-person classroom study annually for re-licensure and encourages doctors of chiropractic to attend local, state, and national meetings to foster better understanding, cooperation, and unity within our profession. (Ratified by the House of Delegates, March 2002).
Resolved, that the following is the ACA policy on diplomate status: A diplomate is a specialist within the healing arts. The diplomate has completed a course of study in a specific healthcare discipline and/or domain (specialty or subspecialty) of a discipline. A healthcare board in his specific discipline has credentialed the successful diplomate. The diplomate maintains and enhances his skill, knowledge and abilities through scholarly endeavors and periodic re-certification. (Ratified by the House of Delegates, September 2000).
Diplomate programs are postdoctoral courses available in various aspects of chiropractic practice. They are in-depth programs requiring a complete foundation of basic medical/chiropractic education.
Diplomate programs have always been the purview of the field practitioner; and most chiropractic colleges allow only licensed doctors of chiropractic to attend diplomate programs. Therefore, be it
Resolved, that the ACA commend chiropractic colleges for conducting postdoctoral diplomate courses for licensed field doctors of chiropractic. Be it further
Resolved, that diplomate programs should be and remain available for doctors of chiropractic. Be it further
Resolved, that the opening of diplomate programs to individuals who do not possess a doctor of chiropractic degree may serve to dilute the value, credibility, and status of diplomates and diplomate programs. (Ratified by the House of Delegates, July 1995, Reaffirmed, June 1998).
Resolved, that the American Board of Chiropractic Specialties (ABCS) study and correlate the postgraduate syllabi for the transfer of credits to avoid duplication of the educational requirements for specialty education credits. (Ratified by the House of Delegates, August 1999)
Resolved, that the specialty councils and their respective boards be notified by letter that unrealistic and perceived punitive re-certification requirements should not be imposed on their respective membership and that these requirements should not be used as criterion for credentialing in any managed care or third party payer plan. (Ratified by the House of Delegates, August 1999)
Post Graduate and Continuing Education
Resolved, that the ACA House of Delegates adopts the following position on Chiropractic Postgraduate and Continuing Education.
The American Chiropractic Association recognizes that the extensiveness of accumulated knowledge and rapid growth of new knowledge requires that today's doctors of chiropractic continue their education throughout their professional careers. The ACA is in accord with the concept of requiring continuing education as a requisite to chiropractic license renewal.
The ACA recognizes, supports and encourages all programs and endeavors in postgraduate and continuing education which are of acceptable academic and ethical quality and which are presented in the best interests of the profession. Generally, the following areas of interests and sources of postgraduate and continuing education my be considered to be among those appropriate for professional growth, and meeting the requirements of the profession and expectations of society.
1) Programs in basic, clinical and chiropractic sciences and arts, in research, health planning, institutional protocol, insurance practices and procedures, peer review, industrial practices, forensic practices, insurance consultation, labor relations, patient counseling, and practice management.
2) Programs of independent study of professionally related journal articles, monographs, texts, and other materials.
3) Programs relevant to chiropractic presented in conventions, workshops, seminars, and conferences that are presented, sponsored and/or approved by recognized, professionally related associations, organizations, governmental agencies and/or academic institutions having status with accrediting agencies recognized by the U.S. Department of Education.
It is the position of the ACA that only chiropractic academic institutions having status with the Council on Chiropractic Education can and should conduct postgraduate courses leading to eligibility for board certification in specialized or select areas of chiropractic practice.
The ACA, along with CCE, deplores the itinerant, privately conducted continuing education programs which are presented primarily for private gain, as well as the programs which promote unlearned and unscientific concepts and cultism, and the programs which emphasize the pecuniary interests of chiropractic practitioners above the best interests of the public and the profession. (Ratified by the House of Delegates, June 1982).
• In your professional judgment and consistent with best practices, is an extended treatment plan medically necessary and do you anticipate being able to document progress?
• Would such an arrangement place your financial benefit over the actual clinical need of the patient?
• Would the manner in which you propose the arrangement create the perception of any undue pressure on the patient to sign the contract or agreement?
• Have you made every effort to assure the patient’s clear understanding of the terms of the written contract or agreement?
• Do you plan on providing the patient with a written copy of the contract or agreement?
• Would instituting a pre-payment policy constitute a dual fee schedule? In situations where patients may not have existing coverage with a private insurer, to offer a discount to these uninsured patients may still constitute a violation of the contractual agreements you have entered into with insurers or other entities.
• Would instituting a pre-payment arrangement violate any contracts that you may have with private insurers regarding provisions delineating the collection of fees? If the patient has private insurance that will cover portions of the cost of care, it may also be a violation of the participating contract to reduce co-payments and deductibles via the pre-payment discount if a financial hardship has not been documented.
• Should the patient determine that they no longer wish to continue care which has been pre-paid, have you implemented a policy of refunding monies for care not rendered? Would the patient’s termination of such a contract or agreement incur any financial penalty or inconvenience?
• Have you consulted an administrative law or healthcare law attorney from your state to determine the legality of a pre-payment arrangement?
• In lieu of legal counsel, have you determined if there are any laws, state statutes, board rulings, or regulations, et cetera, that apply to pre-payment arrangements?
In summary, pre-payment arrangements should be for the benefit of your patient, but should also take into account the ethical, legal, and contractual obligations you have as a doctor of chiropractic.
DISCLAIMER: This policy is intended to address many frequently asked questions about prepayment plans and to highlight aspects that require further clarification. The policy was developed as an educational tool for ACA members and the policy is designed to provide accurate and authoritative information, and as such is not intended as legal or other professional advice. Members interested in these types of prepayment plans are encouraged to obtain the advice of competent legal counsel.
Chiropractic physicians based on their education, training and experience provide essential services to treat the human body. Chiropractic physicians focus on prevention, health promotion and wellness from the inception of care. Doctors of chiropractic address multiple stress factors (physical, chemical and emotional) by utilizing stress management procedures and counseling patients on healthy habits and risk avoidance. Doctors of chiropractic also recommend and manage dietary changes, nutritional interventions, botanical medicines, homeopathic medicines, acupuncture and other services when indicated. Essential services provided by a chiropractic physician are conservative approaches that are widely utilized by the American public and have been shown to benefit patients with many of the conditions that present in a primary care setting. More than 70,000 chiropractic physicians practice across the nation, often in medically underserved areas acting as usual source providers delivering portal of entry care. Like other primary care providers (PCPs), chiropractic physicians are well trained in differential diagnosis, and appropriate referrals. This training and licensure enables doctors of chiropractic/chiropractic physicians to refer patients for treatment options.
According to the 2010 National Board of Chiropractic Examiners Practice Analysis of Chiropractic, "In the United States Chiropractic is the nation's third largest primary healthcare profession, surpassed in numbers only by practitioners of medicine and dentistry. It is the largest, most regulated, and best recognized of the complementary and alternative professions. All 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands officially recognize chiropractic as a primary healthcare profession.. Primary care is accessible, first-contact health care without the necessity of a referral.
A 2007 study, documenting the benefits of chiropractic physicians functioning as primary care providers utilizing a nonsurgical/non-pharmaceutical approach, showed a significant reduction in both clinical utilization and cost factors compared to the use of conventional allopathic medicine alone.1 Furthermore, chiropractic physicians are uniquely trained to address health promotion, prevention, wellness and neuromusculoskeletal ailments, and the number of patients presenting with these types of essential needs are continually rising. A May 2009 article in the American Journal of Lifestyle Medicine indicated that lower back problems are considered the most prevalent pain complaint affecting the general population, with a reported lifetime prevalence of up to 75 percent. According to February 2010 data from the U.S. Department of Veterans Affairs, more veterans returning from Iraq and Afghanistan have sought treatment for diseases of neuromuscular and musculoskeletal systems/connective tissue system than for any other physical malady.
Not only are neuromusculoskeletal conditions widespread, they are costly. A 2008 article from the Journal of the American Medical Association (JAMA) reported that the cost of treating spinal pain has become the sixth most expensive medical condition in America at $86 billion in 2005--a 65 percent increase since 1997. Chiropractic physicians provide unparalleled expertise in the neuromuscular and musculoskeletal systems and can cost-effectively treat the conditions (F4CP Report, Milstein) plaguing an increasing number of Americans. Additionally, doctors of chiropractic routinely treat patients to prevent the majority of the top ten most expensive health conditions in the United States including treatment of trauma disorders, prevention of diabetes and high blood pressure, and treatment of osteoarthritis and back pain. Management of trauma disorders, diabetes, high blood pressure, osteoarthritis and back pain cost the health system 268 billion dollars annually according to the Agency for Healthcare Research and Quality (AHRQ). Chiropractic physicians are also well trained in lifestyle counseling on topics such as obesity which is quickly becoming a national pandemic.
In summation: Doctors of chiropractic are well-trained to provide primary care services. Chiropractic physicians/doctors of chiropractic have pioneered conservative healthcare and has been the leading provider of these essential services that are safe and effective. Chiropractic healthcare enjoys high patient satisfaction, and outcomes that may control costs, enhance the primary care setting and the health of the American people.
1 Sarnat R, Winterstein J, Cambron J. “Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association: An Additional Three Year Update” JMPT 2007: 263-269.
The ACA recommends that ATVs not be sold as toys for children; ATV drivers be licensed and appropriately trained in driving an ATV and in safety measures regarding the ATV, particularly the utilization of proper safety equipment to include safety helmets. ACA also recommends that ATV manufacturers investigate redesigning the ATV to include: passenger restraint system, safety roll bars and automatic engine shut-offs in case of accident or roll over. (Ratified by the House of Delegates, July 1987).
ACA supports a uniform drinking age of 21 to be adopted legislatively in all states to help curb the increasing numbers of accidents and deaths due to teenage drinking. (Ratified by the House of Delegates, July 1987).
Resolved, that the ACA supports the use of safety helmets for both the driver and the passenger of motorized two and three wheel vehicles; which would help to prevent serious injuries and traffic fatalities, and is in the best interest of the general public. (Ratified by the House Delegates, June 1985).
Resolved, that the American Chiropractic Association does support the implementation of passive restraints/seat belts and headrests for use in public transportation. Seat belt restraints have a proven record for prevention of serious injury and/or death resulting from vehicular trauma. We believe it is in the interest of public safety that passive restraints/seat belts and headrests be made available for all form of public transportation. (Ratified by the House of Delegates, September 2000).
Resolved, that the ACA recommends the use of safety equipment where relevant, for recreational activities for both child and adult participants. (Ratified by the House of Delegates, June 1989).
Resolved, that the American Chiropractic Association endorses the use of seat belts or passive restraints, and recommends appropriate safety devices for children that all states in the U.S. which do not currently have laws requiring their use by drivers and passengers of all ages, introduce such laws to their legislatures. Furthermore, the American Chiropractic Association recommends that all state and local chiropractic associations work for the passage and the strict enforcement of such laws in a campaign to safeguard the American public. (Ratified by the House of Delegates, June 1985).
Resolved, that the American Chiropractic Association study the feasibility of a national program to employers to institute ergonomics programs - particularly job safety training - to help reverse the national trend of out-of-control workers' compensation costs and the negative impact on-the-job injuries have on the competitiveness of our national economy. (Ratified by the House of Delegates, September 2004).
However, there exists within the profession individuals and groups, which attempt to utilize what appears to be or may in fact be research efforts as a means to solicit patients. Such research/patient solicitation efforts erode the credibility of legitimate chiropractic research and threaten to endanger the professional relationship between patient and chiropractor.
Therefore, be it resolved that the American Chiropractic Association encourage research by individual doctors of chiropractic, e.g. case studies, as part of a continuing learning process that will ultimately result in better practitioners. This research will also contribute to the ever-growing body of knowledge and to a better understanding of the benefits of chiropractic care. Chiropractors are encouraged to participate in and support chiropractic research as part of their commitment to the chiropractic profession.
Be it further resolved that the American Chiropractic Association recognizes that a normal part of the everyday chiropractic practice involves communication in some form that will allow members of the public to better understand the benefits of chiropractic care and to recognize the services available from a specific doctor of chiropractic. This communication can take many forms of advertising and marketing. Ultimately, this communication is governed by applicable federal and state laws as well as specific chiropractic codes of ethical conduct.
Be it further resolved that the American Chiropractic Association caution its members that it regards the practice of utilizing research programs for the designed purpose of patient solicitation to be an unacceptable and possibly illegal method of patient inducement that will ultimately damage the credibility of chiropractic as a whole and in particular damage the credibility of chiropractic research.
Chiropractic examining boards and other authorized governmental regulatory agencies are encouraged to investigate and to take proper action in regard to these improper patient solicitation/research programs. (Ratified by the House of Delegates, June 1991).
Resolved, that the ACA make the national PTA and other appropriate organizations aware of ACA's support, thereby opening dialogue on ways to further promote the health and wellness of school-age children.
Resolved, that the National PTA and its constituent organizations promote the importance of healthy eating among children and youth to combat the growing national epidemic of childhood obesity; and be it further
Resolved, that the National PTA and its constituent organizations support the inclusion of parents, community and health specialists along with educators and administrators when determining whether or not vending machines should be allowed on the school grounds and, if so, also be involved in deciding the types of products allowed within those machines and the use of proceeds garnered.
Resolved, that the National PTA and its constituent organizations support the requirement that food and beverage items sold to students in vending machines, school stores, and in the school cafeteria contain at least the minimum nutritional value as determined by the USDA. (Ratified by the House of Delegates, September 2004).
Be it Resolved: That it is the ACA’s position that the scope of practice of chiropractic physicians and post-doctoral chiropractic specialties should be determined by the education and training provided within CCE accredited institutions and/or the education and training provided through post-graduate / post-doctoral courses and specialties and; Be it further Resolved: The ACA encourages individual states and US Territories to establish uniform scopes of practice commensurate with contemporary education and training.
Resolved, that ACA recognize the World Federation of Chiropractic (WFC) efforts in supporting the WHO in the area of tobacco control and its establishment of a "Health-for-All Committee" which has set the anti-tobacco initiative as its first priority and will be developing guidelines for defining a role for doctors of chiropractic world-wide in this multi-disciplinary endeavor to improve human health.
Resolved, that ACA support the United States government efforts in tobacco control, including those put forth by the United States Public Health Service (USPHS), and the Office of the Surgeon General.
Resolved, that ACA encourage all doctors of chiropractic to incorporate anti-tobacco messages to every patient, and provide guidance for tobacco use cessation to patients who express an interest in them.
Resolved, that ACA recognize observance of the WHO annual No Tobacco Day on May 31 each year and the Great American Smoke Out on the third Thursday of November each year.
Resolved, that ACA prohibit cigarette smoking and other tobacco product use at all ACA events and at ACA's Headquarters.
Resolved, that ACA encourage all DCs to discourage any tobacco product use in their offices, and to set positive examples themselves by not using any tobacco products. (Ratified by the House of Delegates, September 2001).
Resolved, that the American Chiropractic Association, in the interest of the public's health and that of chiropractic patients, highly encourage a tobacco-free lifestyle, condemns cigarette smoking and the use of tobacco products for their negative affects on the spine and surrounding tissues, as well as their detriment to overall health and wellness. (Ratified by the House of Delegates, September 2004).
In this current era of electronic communications, the illusion of personal privacy in web related interactions, and the ease with which information can be used outside of its intended electronic context, it would be wise to consider the following areas identified to be the most commonly misunderstood aspects of digital communication as part of interpersonal interactions:
- Establish and implement professional boundaries for the digital doctor/patient relationship: Unlike face to face communications with patients, there is no way to verify, with absolute certainty, the actual identity of the person with whom you are interacting online, nor can you control with whom that interaction is shared. It is often seen that doctors of chiropractic will “friend” their patients or maintain a “close” social tie with them. Publicly posting information containing private patient information or even publicly acknowledging a doctor-patient relationship could jeopardize the patients’ right to privacy by violating HIPAA. If a doctor feels compelled to establish a close social networking tie with a patient, it would be well advised that the doctor refrain from any public communication about any private health care information about the patient. Private online discussion of that business relationship should be treated as public as NOTHING is completely secure online.
- Privacy and confidentiality: Virtually everything that is online is discoverable despite our best efforts to keep them secure. Examples of hacks, leaks and security breaches are frequently in the news. So, whether you are writing on your blog, commenting on a news article, posting messages or pictures on Facebook or tweeting your most recent professional developments, remember that information that can be accessed by most people can easily be taken out of context and can greatly harm your reputation. It is best to exercise the following discretion: If I would not openly share it in the lobby of my practice, would it be wise to post it online?
- Ethics and professionalism online and offline. It is common to conduct yourself in a professional manner when at professional functions such as trade shows, holiday parties and even meet and greets, but the same discretion is now necessary at all functions as it is entirely possible that you are photographed during a less than perfect moment and that picture ends up in an online context. Such information could raise question regarding your suitability to treat patients and can even result in disciplinary measures by your licensing board
- Separation of one’s personal and professional identity online: To whatever extent possible, separation of personal and professional identities online is always recommended. As such, whenever possible, sharing health information should be primarily from a separate business page (i.e. a practice Facebook page vs. a personal Facebook page.) However, the personal and professional identities and content are never truly separate; therefore, it is wise to consult point 3.
- Provision of medical advice online; a liability: It is natural to want to help a patient or even a friend online, if the question seems simple. Please know, however, such a practice can place you and your office at significant risk as this may form a doctor-patient relationship where the doctor now owes a duty to the patient and creates unnecessary liability.
- Inflating credentials. Your credentials should precisely represent the content of your diplomas and certificates hanging on the wall in your office.
- Be aware of content and how it can be misconstrued/ misunderstood. IF you do consider posting health information online, consider posting references supporting the information. Information posted on the internet is frequently not factual and it is wise to personally fact check information if you are considering sharing it with your social media followers.
- Understand the rules and regulations (Federal and State) related to social media usage. New federal and state guidelines concerning social media are frequently developed and staying current with regulations that affect your social media use is advised.
The primary goal in caring for the elderly should be to maximize function and achieve the highest level of well-being in everyday life activities. This will require the development of creative new ways to keep senior citizens functionally independent -- including the utilization of chiropractic care. In the long run, this may help to reduce costs.
The American Chiropractic Association (ACA) has long recognized that spinal and neuromusculoskeletal health care are essential for the total health and well-being of the elderly. Such health care ' aids in maintaining proper mobility and freedom from, or reduction of, neuromusculoskeletal and joint pain -all critical factors in enhancing independent living and quality of life.
The ACA recommends that senior citizens must be able to have access to, and freedom to choose, chiropractic, spinal and neuromusculoskeletal care. The ACA further recommends that health maintenance organizations (HMOs) and managed care organizations should not exclude or prevent chiropractic services to elderly patients. Also, the Medicare benefit for chiropractic services needs to be updated, to include x-rays required for Medicare reimbursement; and expanded to cover services, which are currently provided to elderly patients by Doctors of Chiropractic, but are not reimbursable.
A primary objective of elderly care, by all health care providers, should be the concept of "Healthy Aging." Such factors as nutrition and diet, exercise and fitness, safety and fall prevention, lifestyle, living conditions, intellectual stimulation, social support, and disease prevention all contribute to a healthy lifestyle and an enhanced quality and dignity of life. The ACA also recommends that educational programs be conducted for the public and health practitioners to encourage preventive, inter-disciplinary care for the aging. In addition, long-term care for the elderly is a priority, and should be provided humanely and cost-effectively. (The text printed above is an abstract of a policy statement ratified by the House of Delegates, July 1995. A copy of the complete policy statement is available from ACA headquarters).
It is incumbent upon the chiropractic profession to continue its research to exponentially expand the gathering of scientific evidence on quality and affordable health care, especially in the area of chiropractic spinal manipulation/adjustment. It was, therefore, agreed by Committee members that a high-level policy statement on chiropractic spinal manipulation/adjustment be developed to invite further research and to facilitate widespread public understanding. Recommendations include:
- Develop a research program to enhance future studies of chiropractic spinal manipulation/adjustment.
- Create medical profession awareness about the benefits of early, integrated chiropractic care to restore and maintain spinal health.
- Disseminate this important safety and quality information to consumers, policymakers and payers. (Ratified by the House of Delegates, August 1999)
Medically necessary care of acute conditions is care that is reasonable and necessary for the diagnosis and treatment of a patient with a health concern and for which there is a therapeutic care plan and a goal of functional improvement and/or pain relief. The result of the care is expected to be an improvement, arrest or retardation of the patient’s condition. Initially, the care may be more frequent, but as levels of improvement are reached, a decrease in the frequency of care is to be expected. A patient may experience exacerbations of an acute injury/illness being treated that may clinically require an increased frequency of care for short periods of time. A patient may also experience a recurrence of the injury/illness after a quiescence of 30 days that may require a reinstitution of care.
Management of Chronic/Recurrent Conditions
Medically necessary care of recurrent/chronic conditions is care that is provided when the injury/illness is not expected to completely resolve following a treatment regimen, but where continued care can reasonably be expected to result in documentable improvement for the patient. When functional status has remained stable under care and further improvement is not expected or withdrawal of care results in documentable deterioration, additional care may be necessary for the goals of: supporting the patient’s highest achievable level of function, minimizing or controlling pain, stabilizing injured or weakened areas, improving ADLs, reducing reliance on medications, minimizing exacerbation frequency or duration, minimizing further disability or keeping the patient employed and/or active. Chronic/recurrent care may be inappropriate when it interferes with other appropriate primary care or when its benefits are outweighed by its risks, e.g., psychological dependence on the physician or treatment, illness behavior or secondary gain.
Management for Wellness
Achieving wellness requires active patient participation. Wellness is a process of achieving the best health possible, given one's genetic makeup, by pursuing an optimal level of function. “Optimizing levels of function” may include a combination of health care strategies such as chiropractic adjustments, manipulative therapy, manual therapies, exercise, diet/nutrition counseling and lifestyle coaching.
Resolved, that chiropractic practice may include a variety of responses to a particular clinical problem and that adherence to any particular guideline is voluntary. Except where provided otherwise, all practice guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of a specific procedure must be made by the practitioner in light of the individual circumstances presented by the patient.
Be it further resolved that in formally endorsing the process and draft guidelines, the ACA takes specific exceptions to those areas in the document which may be inconsistent with existing ACA policy, and affirms that the guidelines are subordinate to federal and state law, whether by statutes, regulations, court decisions, or otherwise.
The House of Delegates recommends that the document be reviewed in detail at the 1994 Annual Meeting, which will allow for meaningful critiques from the chiropractic practitioners in the field. (Ratified by the House of Delegates, May 1992)
Whereas, the practice of chiropractic includes the investigation, examination, and diagnosis of conditions of the human body and the treatment of such conditions by clinical procedures to include but are not limited to chiropractic manipulation / adjustments, physiotherapy, and the administering or dispensing of orthopedic appliances and/or clinical nutrition including vitamins, minerals, herbals, homeopathic and other nutritional supplementation; and
Whereas, orthopedic appliances and nutritional medicines, when administered or dispensed by doctors of allopathic medicine or osteopathic medicine, are generally exempt from state sales tax. Therefore, be it
Resolved, that the American Chiropractic Association acknowledge that the orthopedic appliances and/or nutritional supplements / articles dispensed or administered during the professional course of practice by a doctor of chiropractic, should be considered exempt from state sales tax. (Ratified by the House of Delegates August 2002)
As is commonly taught in all chiropractic educational institutions, it is appropriate to manipulate/adjust a segment(s) that may not be symptomatic and/or located in the same spinalregion as the area of chief complaint. These segments are identified through objective measures and should correlate clinically and have a direct therapeutic effect.
Example: Patient with a chief complaint of headache. Objective findings of segmental dysfunction at C.1-2. Further biomechanical evaluation reveals the presence of lower lumbar and pelvic segmental problems contributing to a postural condition affecting the cervical region. It would be appropriate to manipulate/adjust all affected segments and report the appropriate AMA CPT code , consistent with the level of work performed (number of body regions manipulated/adjusted), for that service.
Resolved, that the American Chiropractic Association and Council on Sports Injuries and Physical Fitness simultaneously seek inclusion of doctors of chiropractic into the Tem Physician Consensus Statement by using all appropriate means necessary to promptly, definitively and equitably resolve this issue. (Ratified by the House of Delegates, August 2001).
It is important to note that ACA policy does not in any way supersede state or federal law or regulation or any contracts or policies of insurance carriers.
Constant Attendance Modality codes (97032 – 97039) are used to report various physical agents applied to the patient for the purpose of producing therapeutic changes to biological tissue. The codes do require direct one-on-one contact for treatment. Direct one-on-one contact requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the procedure.
These time-based codes include the time required to perform all aspects of the service itself, including pre-, intra-, and post-service effort. The language in the constant attendance modality codes indicates that these codes are reported once for each 15 minutes of service. For example, if manual electrical stimulation is applied to four areas for a total of 30 minutes, CPT code 97032 is reported for two units, once for each 15-minute interval. If a substantial portion of the 15 minutes time-based service is not provided, then the service should not be billed or the Reduced Services modifier -52 should be appended to the code to identify the reduction of service.
Therapeutic Procedures (codes 97110-97546) were added to CPT 1995 to clarify the differences between Therapeutic Procedures, Modalities, and Tests and Measurements. A Therapeutic Procedures is defined as “a manner of effecting change through the application of clinical skills and/or services that attempt to improve function.” These procedures require direct one-on-one patient contact by a physician or therapist. The descriptions for most of these codes reflect 15-minute intervals. If a procedure lasts more than 15 minutes, the CPT codes can be reported for each 15-minute interval. For example, if therapeutic exercise is performed for 30 minutes, 97110 will be reported for two units.
Common components included as part of Therapeutic Procedures include chart reviews for treatment, setup of activities and the equipment area, and review of previous documentation as needed. Also included is communication with other health care professionals and discussions with the patient’s family. Subsequent to providing the therapeutic service, the treatment is recorded, and typically, the progress is documented. The patient health record should list the duration of the procedure time.
Therapeutic Procedures are intended to be performed with one-on-one patient contact. If a provider is performing Therapeutic Procedures in a group of two or more individuals, CPT® code 97150 will be reported. Time and/or the number of Therapeutic Procedures are not defined in this code.
For example, a practitioner spends 10 minutes working with patient X on therapeutic exercises to develop strength and endurance. The practitioner instructs patient X to continue the exercises for 5 or more minutes and attends to another patient, patient Y, during this time, while continuing to supervise patient X. The practitioner returns to patient X and spends another 5 minutes directly working with him, and once again instructs patient X to continue a particular exercise for 5 minutes. The practitioner again attends to patient Y during this time, then returns to patient X to work directly with him for another 5 minutes. Should code 97150 be reported, or should code 97110 be reported twice?.
From a CPT coding perspective, code 97110 requires the practitioner to maintain direct patient contact (i.e., visual, verbal, and/or manual contact) during provision of the service. CPT code 97110 is to be reported when the practitioner is providing therapy to only one patient. When the practitioner is working with several patients at the same time, then CPT code 97150 should be reported. The specific type of therapy provided (e.g., 97110) should not be reported in addition to the group therapy code.
According to the December 2009 CPT Assistant, “…it is important to recognize that a substantial portion of the 15 minutes must be spent in performing the pre-, intra-, and post service work in order to report the timed code. If only a few minutes are spent performing the physical medicine service, the code shall either not be billed or modifier 52 should be appended to the code. The provider has the responsibility to document that the services rendered are medically necessary, skilled, and of good practice.”
Medicare guidelines are different and state that providers should report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as “intraservice care” begins when the therapist or physician or assistant under the supervision of a physician or therapist is delivering treatment services. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.
The time counted is the time the patient is treated. For example, if gait training for a patient with a recent stroke requires both a therapist and an assistant, or even two therapists to manage the patient or the parallel bars, each 15 minutes the patient is being treated can only count as one unit of 97116. The time the patient spends not being treated because of the need for toileting or resting should not be billed. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time.
For any single CPT® code, providers would bill Medicare a single 15-minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes. If the duration of a single modality or procedure is greater than or equal to 23 minutes to less than 38 minutes, then 2 units should be billed. Time intervals for larger numbers of units are as follows: 3 units > 38 minutes to < 53 minutes 4 units > 53 minutes to < 68 minutes 5 units > 68 minutes to < 83 minutes 6 units > 83 minutes to < 98 minutes 7 units > 98 minutes to < 113 minutes 8 units > 113 minutes to < 128 minutes
The pattern remains the same for treatment times in excess of 2 hours. Providers should not bill for services performed for < 8 minutes. The expectation (based on the work values for these codes) is that a provider’s time for each unit will average 15 minutes in length. If a provider has a practice of billing less than 15 minutes for a unit, these situations should be highlighted for review.
The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the 8th should be excluded from the total count as the timing of active treatment counted includes all time.
It is advisable that the beginning and ending time of the treatment should be recorded in the patient’s medical record along with the note describing the treatment. If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time, see examples below.
Example 1: If 24 minutes of 97112 and 23 minutes of 97110 were furnished, then the total treatment time was 47 minutes, so only 3 units can be billed for the treatment. The correct coding is 2 units of 97112 and one unit of 97110, assigning more units to the service that took more time.
Example 2: If a therapist delivers 5 minutes of 97035 (ultrasound), 6 minutes of 97140 (manual techniques), and 10 minutes of 97110 (therapeutic exercise), then the total minutes are 21 and only one unit can be paid. Bill one unit of 97110 (the service with the longest time) and the clinical record will serve as documentation that the other two services were also performed.
Supervised modalities 97010-97028 are used to report various physical agents applied to the patient for purposes of producing therapeutic changes to biological tissue and do not require one-on-one contact and are not time-based.
Discrimination exists and harms the insuring public when health or other insurance products are denied to individuals who treat or have been treated by a doctor of chiropractic in the past. The mere suggestion, let alone insurance denial or the attachment of a limiting waiver, are biased acts and represent a gross misunderstanding of the chiropractic profession and its preventive and healing abilities. An applicant is not less underwriting worthy because of chiropractic treatment alone.
Often chiropractic patients are seen for preventive or wellness care that does not involve an injury or existing condition. Chiropractic treatment is not invasive and does not cause the inherent complications or disability of the spine or other structures, as do surgical interventions or certain therapeutic procedures. Chiropractic wellness or maintenance care is provided to prevent[s] the recurrence of an injury or condition as a safeguard to more invasive or potentially higher risk acute care, which can present potential complications. Additionally, chiropractic wellness care seeks to keep the patient/employee healthy, active and productive, thus controlling the additional costs associated with lost time from work.
A code of ethics exists for underwriters that require at a minimum to: 1
- keep paramount the needs of those whom I serve.
- respect my client's trust in me, and to never do anything that would betray their trust in me.
- present policies factually and accurately, providing all information necessary for the issuance of sound insurance coverage to the public I serve.
- ?abide by the laws of any jurisdiction Federal or State, in which I practice and seek constantly to increase my knowledge and improve my ability to meet the needs of my clients.
- extend honest and professional conduct?.
It is incumbent for the underwriting community to seek new knowledge and incorporate that knowledge into existing practices and procedures to serve the public fairly. It is therefore ACA's intention to share this statement with state insurance regulators who can provide oversight and assess underwriting market conduct within their respective state. The statement may also be requested by insures, underwriters, independent agencies, patients and doctors of chiropractic to ensure insurance products are executed in good faith in relation to treatment by a doctor of chiropractic.
1 National Association of Health Underwriters' Code of Ethics: http://www.nahu.org/
(Ratified by the House of Delegates, March 2005.)
Since the scientific community acknowledges that the use of vaccines is not without risk, the American Chiropractic Association supports each individual's right to freedom of choice in his/her own health care based on an informed awareness of the benefits and possible adverse effects of vaccination. The ACA is supportive of a conscience clause or waiver in compulsory vaccination laws thereby maintaining an individual's right to freedom of choice in health care matters and providing an alternative elective course of action regarding vaccination. (Ratified by the House of Delegates, July 1993, Revised and Ratified June 1998).
Resolved, that the term "veterinary chiropractic" is a misnomer, and should not be used when referring to the application of manipulative techniques to animals. (Ratified by the House of Delegates, July 1994).
The recommendation of nutritional supplements should include a nutritional assessment of the patient.
The practitioner shall record the rationale for the supplements in the patient's chart.
The doctor should attempt to determine that the products being recommended are not experimental.
The ACA's Council on Nutrition holds the position that it is appropriate for a doctor of chiropractic to recommend the use of vitamins, minerals and food supplements, in conjunction with weight control programs, to the extent this is not in conflict with state statutes and regulations.
A nutritional assessment should be made of the patient prior to the use of nutritional supplements, and duly recorded in the patient's file.
Doctors should attempt to determine that products used for weight control are not experimental.
Further, the doctor should request of the companies with which they are doing business research reports from independent sources regarding their products. (Ratified by the House of Delegates, June 1991).
Since its inception, chiropractic has been based on an active care model that emphasizes health promotion and wellness. Health Promotion is the science and art of helping people change their lifestyle toward a state of optimal health. Wellness is a process of optimal functioning and creative adaptation involving all aspects of life. Health is a state of optimal well being and functioning: Wellness is an active process employing a set of values and behaviors that promotes health and enhances quality of life.(1)
Wellness care incorporates active lifestyle changes consistent with the goals of Healthy People 2010 and those proposed for Healthy People 2020(2).
Wellness begins on day one of chiropractic care. As an active care model, the commitment of the doctor of chiropractic to wellness emphasizes collaboration with patients on the development of a lifelong path for health promotion and disease prevention.(3) Health promotion and wellness are based on a patient-centered paradigm. (4) Incorporating knowledge, skills and attitudes acquired through professional training, the doctor of chiropractic works with patients as partners in a number of domains, including:
- • Evaluation/Assessment of Patients (risk factors, health needs)
• Information/Education of Patients (awareness)
• Intervention/Monitoring (including counseling)
• Integration with other Community Resources
Evaluation/Assessment of Patients:
As an integral part of the routine history and examination process, the doctor of chiropractic uses appropriate instruments and procedures to determine, a) his/her assessment of the patient's health and wellness needs; and b) the patient's perception of his/her health and wellness needs. This stage represents the initial assessment of the patient's current health status, and includes identification of constitutional (genetic), behavioral, and environmental risk factors.
- 1. Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2010 Objectives, Clinical Preventive Care. Section 1-2. (Developmental) "Increase the proportion of insured persons with coverage for clinical preventive services." Section 1-3. "Increase the proportion of persons appropriately counseled about health behaviors." Web Link
2. ACA Resolution 2000  - 4: Chiropractic Wellness Campaign, June 2000.
Information/Education of Patients:
The doctor of chiropractic determines a working diagnosis and communicates this to the patient, along with strategies for meeting his/her health and wellness needs. The doctor and patient then discuss a management plan, taking into consideration the risks, benefits, and lifestyle implications of selected strategies. A plan for immediate, intermediate, and long-term health promotion andwellness care, based upon both the doctor's assessment and the patient's perception of health and wellness needs, is negotiated.Intervention/Monitoring:
The patient consents to treatment and agrees to initiate the selected health promotion and wellness care plan. The case of a patient who presents to the doctor of chiropractic with a complaint of acute low back pain is used to illustrate the concept of immediate, intermediate, and long term health promotion and wellness care. The assessment reflects that the patient is also obese, a smoker, and has high normal blood pressure. These issues are then addressed in relation to the patient’s current condition and general health.
- • The immediate intervention focuses on decreasing the patient's pain and returning him/her to normal daily function and activities. From day one of intervention, the doctor of chiropractic makes health and wellness recommendations to optimize recovery and prevent recurrence.
• During the intermediate phase, the spinal care is continued, and the patient's obesity and elevated blood pressure are addressed through lifestyle modifications, including diet and exercise.
• Long-term active/wellness care includes continued attention and assessment of the patient's progress in order to identify changing health needs and to facilitate self-reliance and personal well-being.
The doctor of chiropractic monitors the patient's progress and suggests appropriate modifications to intervention (treatment) strategies based upon changing health and wellness needs of the patient.Integration with Other Community Resources:
The doctor of chiropractic serves as a resource to the community for health care, health promotion, and wellness. As a direct access provider, he/she serves as a conduit to other health care practitioners, services and information resources. The various levels of traditional prevention include:
- • Primary Prevention: prevents a disease or condition from occurring.
• Secondary Prevention: detects early signs of a condition or disease and intervenes.
• Tertiary Prevention: reduces sequellae and is supportive or rehabilitative in nature.
Primary Roles of the Doctor of Chiropractic
Chiropractic health promotion and wellness care goes beyond traditional preventive care that focuses on disease and pathology. The traditional chiropractic approach seeks to optimize function. The primary roles of a doctor of chiropractic include, but are not limited to:
- 1. Primary Care/Portal of Entry/Direct Access Practitioner
2. Health Information Resource
3. Health and Wellness Advocate
4. Disease Prevention Manager
5. Injury Prevention Manager
6. Health Screening Advisor and Provider for Early Detection of Disease
7. Spinal, Musculoskeletal and Biomechanical Care Specialist Within the Health Care System
Tasks of a Doctor of Chiropractic
The following information is representative of the types of health promotion activities that are commonly preformed by the doctor of chiropractic in the roles listed above (the activities listed are not all inclusive).Primary Care/Direct Access Practitioner (Primary, Secondary and Tertiary Prevention)
The following are examples of health promotion activities performed by the doctor of chiropractic serving in the role of primary care/direct access practitioner:
- Initial History, Evaluation & Treatment
Direct Patient for Appropriate Consultation and Referral, when indicated
Develop Health Management Contracts with Patient
Provide Conservative Health Care Management for a Broad Variety of Conditions, such as:
- Cardiovascular Disease
Other Conditions and Disorders
The following are examples of health promotion activities performed by the doctor of chiropractic serving as a health information resource:
- Health Status; Self-Assessment for Patients
Battered Child/Spouse Information
Dietary and Dental Health Information
Disease Prevention packages
Age-Specific Health Protection
Emporiatrics: Advice for travelers
Prevention of Sexually Transmitted Diseases
Drugs Used in Pain Relief (Analgesics & Anti-Inflammatory Agents)
Community Resource Information
Family Planning Information
Pregnancy and Maternal Health
The following are examples of health promotion activities performed by the doctor of chiropractic serving as a health and wellness advocate:
- Avoiding or Minimizing Exposure to Pollution
Physical Activity or Exercise (Benefits and Risks)
Nutritional Guidance (RDA, Dist and Disease, Food Processing and Preparation)
Reduced Alcohol Consumption
The following are examples of health promotion activities performed by the doctor of chiropractic serving as an injury prevention manager:
- Athletic Injury Prevention
Automobile Injury Prevention
Musculoskeletal Injury Prevention (Preplacement Screening, Workplace Design)
Childhood Injury Prevention (Vehicle restraints, Bicycle helmets, Backpack Safety)
Geriatrics and Fall Prevention
General Injury Prevention
The following are a few examples of common health conditions for which the doctor of chiropractic may serve as a disease prevention manager:
Other primary care conditions
The following are few examples of common health conditions for which the doctor of chiropractic may serve as a health screening provider for early detection of disease:
Other Primary Care Conditions
Primary: Performing a screening test and finding no abnormalities is categorized as primary prevention.
Secondary: If a screening test is performed and detects correctable abnormalities (latent stage of disease), then it is categorized as secondary prevention.
Tertiary: If screening test is performed and yields findings that indicate disease is already present and must be managed, then it is categorized as tertiary prevention.
Spinal, Musculoskeletal and Biomechanical Care Specialist within the Health Care System (Secondary and Tertiary Prevention)
Doctors of chiropractic are experts in the treatment of neuromusculoskeletal conditions, subluxation complex, biomechanical dysfunction and disease. As spinal, musculoskeletal and biomechanical care specialist, doctors of chiropractic perform the following tasks (this list of tasks is not all inclusive):
- Spinal Hygiene Counseling
Skeletal Health Promotion (Exercise, Calcium, Vitamin D, Early Detection)
Back Pain Management (Low-Back pain of Musculoskeletal Origin, Disability, Intervention)
The Differentiation of Back Pain Attributable to Visceral Pathology
Strength and Conditioning Education and Training
Extremity and Soft Tissue Evaluation and Care
Strategies for implementation of a chiropractic wellness model may include the following activities:
- 1. Recognition by the chiropractic profession that the greatest need in health care today is promotion of health and wellness. (e.g. Dental prophylaxis)
2. Fundamental shift in chiropractic college curricula to emphasize wellness philosophy and strategies for implementation of the wellness model.
3. A campaign to inform health educators in schools, colleges, and universities of the wellness focus of chiropractic practice.
4. Continuing education to foster wellness knowledge, attitudes and skills among practicing doctors of chiropractic and support personnel.
5. Integration and emphasis of the wellness care model in all chiropractic specialty councils.
6. Design and seek funding for research studies that assess the chiropractic wellness model.
7. Educate the public, government agencies, and third party payors about why and how to integrate the chiropractic wellness model.
8. Increase the chiropractic profession's involvement in the American Public Health Association, (APHA).
9. Develop buy-in to the wellness model by all chiropractic organizations.
10. Use publications and the Internet to provide useful materials on wellness to chiropractic practitioners and their patients.
11. ACA has submitted a Memorandum of Understanding for the Healthy People 2010 initiatives as well as joined the Healthy People Consortium for 2020 – continue to be involved with initiatives such as this.
12. ACA Communications Department to develop a public relations campaign based upon the wellness model (t-shirts and slogans, etc.)
13. Continuous assessment of trends in wellness-related fields leads to the on-going update of the wellness model.
14. Following acceptance in the United States, pursue globalization of the chiropractic wellness model.
The ACA views this model as a living document for the purpose of responding to progress points and change in the health care delivery system. (Ratified by the House of Delegates, September 2009).
- 1. Definitions adopted by the Council on Chiropractic Education subsequent to the adoption of health promotion and wellness competencies in January 2007. Gatterman, MI, MA, DC, MEd, “Preventive Medicine, Health Promotion and Wellness.” Dynamic Chiropractic. Dec. 2008.
2. Healthy People 2010: Understanding and Improving Health. U.S. Department of Health and Human Services. November 2000.
3. Hawk C.
4. Gatterman MI. A patient-centered paradigm: A model for chiropractic education and research. J Alternative and Complementary Medicine. 1995; 1:371-386.
The current trend by third-party payers is to institute proprietary radiographic quality standards that are tied to provider reimbursement, the ACA Board of Governors has evaluated the voluntary American Chiropractic College of Radiology X-ray Accreditation Program and finds it is an objective and comprehensive radiographic quality control program. Chiropractors who voluntarily seek and receive accreditation through this program will produce radiographs of consistently high quality, affording an enhanced opportunity for early diagnosis of pathologies that afflict chiropractic patients while maintaining patient exposure doses according to ALARA (As Low As Reasonably Achievable) principles.
Resolved, that the American Chiropractic Association House of Delegates endorses the voluntary American Chiropractic College of Radiology X-ray Accreditation Program for the benefit of all chiropractors and their patients. (Ratified by the House of Delegates, August 1999).
Advertising Free Examinations
Certification of Chiropractic X-Ray Technologists
Since the public interest would be served by the certification of qualified chiropractic radiologic technologists, ACA extends its recognition to the American Chiropractic Registry of Radiologic Technologists (ACRRT) as the only independent professional testing organization in this field. (Board approved, June 1983).
It is recognized that roentgen rays are used by the health sciences for diagnostic or therapeutic purposes. The chiropractic profession utilizes x-ray only for diagnostic purposes and considers their use as one of the major diagnostic tools.
The ACA Commission on Insurance holds that there are two facets to the responsibility of the chiropractic physician in the use of x-ray:
(a) Medical necessity for the radiation exposure to the patient; and
(b) Equality of studies consistent with scientific knowledge and acceptability. (Approved, July 1975).
X-ray is one of the major diagnostic facets in the healing sciences and as utilized by chiropractic physicians is one of the major diagnostic tools of that science. Chiropractic does not use x-rays or radiology therapeutically. The ACA supports the position of the Council on Diagnostic Imaging that declares the importance of diagnostic x-ray in the practice of chiropractic and the position of the council that stresses the adherence to sound radiographic procedures. (Approved, July 1975).
Lateral Bending Views of the Spine
A trend in plain film radiography has been identified wherein multiple lateral bending views of the spine and its components have been performed. The American Chiropractic College of Radiology considers these procedures to be efficacious in only a limited number of circumstances. Certain guidelines of utilization are deemed necessary to safeguard the patient population from unnecessary ionizing radiation.
Therefore, be it resolved that the ACA House of Delegates adopt and approve the ACCR position statement on lateral bending radiographic study, which states:
The American Chiropractic College of Radiology considers the utilization of lateral bending views of the spine be a procedure only to be utilized in limited circumstances and adopts the following guidelines to their production:
a. Are reserved additional views, not considered as part of the initial radiographic examination, unless specific trauma or biomechanical dysfunction is documented by history or clinical evaluation, which suggest findings unobtainable by other means.
b. Are performed initially only in those patients where prior treatment has been unsuccessful or where objective clinical findings or treatment resistive symptom expression suggests an as yet undiscovered occult pathology.
c. Are performed only of the cervical or lumbar spine.
d. Are to be performed sectionally only in the cervical and lumbar areas, unless used to demonstrate flexion of a scoliosis.
e. Repeat utilization is rarely indicated save in those cases where appropriate response to treatment is lacking or where re-injury or exacerbation has been clinically documented. (Ratified by the House of Delegates, June 1991).
Lumbar Oblique Radiographs
While there is little evidence to support routine acquisition of oblique radiographs of the lumbar spine, there is ample evidence to support acquisition of these views if the frontal and lateral views fail to adequately demonstrate therapeutically significant pathology, which is clinically suspected, or where uncertainty exists about a reasonable potential for these diseases to be present. In other words, it is important to take obliques where frontal and lateral views do not confidently rule-in certain pathologies just as it is important to take obliques where frontal and lateral views do not confidently rule-out significant pathology which is reasonably suspected based on clinical examination and history. (The text printed above is an abstract of a policy statement ratified by the House of Delegates, May 1996. A copy of the complete policy statement can be obtained from ACA headquarters).
The chiropractic profession recognizes that diagnostic x-ray examinations, while offering inestimable benefits to the knowledge that is made available, have risks and possible detriments, which must be weighed against those benefits. The ACA stands on record that there should always be clinical evidence of need for diagnostic x-ray examinations before such are performed. Use of x-ray as a routine procedure and from patients' self-referral is not good practice and is not condoned.
Proper measures of patient radiological protection including adequate collimation, filtration, gonadal shielding (when applicable) etc., should always be utilized. ACA admonishes all doctors of chiropractic to use all known measures of proper x-ray protection including proper selection of patients with due reference to age, childbearing status, and other factors, surely including clinical indication of need.
Continuing education programs in radiological health and x-ray safety are and have been offered through the chiropractic colleges, state and national chiropractic associations, and govern mental agencies. The chiropractic profession has been among the leaders in the healing arts in participation in such courses and all D.C.s are urged to avail themselves of these. (Ratified by the House of Delegates, 1967, reaffirmed, 1972).
With the publication of these guidelines and subsequent adherence to these tenets by operators/users, the American Chiropractic College of Radiology (ACCR) no longer considers Spinal Videofluoroscopy as investigational within the chiropractic profession.
Caution and certain avoidances must nonetheless be observed with the use of Videofluoroscopy. Among these are those ill-advised practices, which include, but are not limited to, the following:
1. Spinal Videofluoroscopy is never appropriate in clinical practice to visualize the spinal adjustment or manipulation, nor is it efficacious to employ Videofluoroscopy as a "pre and post" evaluation procedure in conjunction with an adjustment or joint manipulation.
2. Spinal Videofluoroscopy must never be performed without video taping of the procedure. This ensures accurate recording of pertinent information and time of exposure.
3. Spinal Videofluoroscopy serves only as an ancillary diagnostic imaging procedure.
4. Spinal Videofluoroscopy shall never be utilized as a replacement for static radiographic procedures.
5. Spinal Videofluoroscopy shall never be employed as a screening or cursory imaging device.
Laboratories as well as referring practitioners are responsible for the necessary documentation and protocols as stated above, regardless of the source of referral for the examination.
Practitioners utilizing Spinal Videofluoroscopy will adopt rigorous measures to ensure the radiation health and safety of both patient and operator. This includes limiting the examination to the area of clinical complaint, along with the application of appropriate radiation protective devices, inclusive of, but not limited to, lead gowning and filtration.
Prior to the individual or institutional utilization of Spinal Videofluoroscopy equipment shall be adequately prepared by didactic training and practical experience to assure competency of application, and interpretation of both the technical and professional component of Spinal Videofluoroscopy. (Ratified by the House of Delegates, June 1991).