LOCATION OF SUBLUXATION
The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for the treatments. The precise level of the subluxation must be documented by the chiropractor in the medical records.
Area of Spine Names of Vertebrae Number of Vertebrae Short Form or Other Name
Neck Occiput Cervical Atlas Axis 7 Occ, CO C1 through C7 C1 C2
Back Dorsal or Thoracic Costovertebral Costotransverse 12 D1 through D12
T1 through T12
R1 through R12
R1 through R12
Low Back Lumbar 5 L1 through L5
Sacral Sacrum, Coccyx S, SC
Pelvic Ilia, R and L I, Si
In addition to the vertebrae and pelvic bones listed, the ilii (R and L) are included with the sacrum as an area where a condition may occur that would be appropriate for CMT.
There are two ways the level of the subluxation may be specified:
* The exact bones may be listed, for example, C5, C6, etc.
Or,
* The area may suffice if it implies only certain bones such as:
* Occipito-atlantal (occiput and C1 (atlas)).
* Lumbosacral (L5 and sacrum).
* Sacroiliac (sacrum and ilium).
There are three categories of conditions:
* Acute – A patient’s condition is considered to be acute when the patient is being treated for a new illness or injury. The result of chiropractic treatment is expected to be an improvement in, arrest or retardation of the patient’s condition.
* Chronic – A patient’s condition is considered chronic when it is not expected to completely significantly improve or be resolved with further treatment (as is the case with an acute condition), but where continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition without expectation of additional functional improvement, further manipulation treatment is considered maintenance therapy and is not covered.
* Maintenance Therapy – A treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition is not a Medicare benefit. Once the maximum clinical benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically reasonable or necessary and is not payable under the Medicare program. An Advance Beneficiary Notice of Noncoverage (ABN) is required.
