Important Medicare Definitions

Acute Treatment

CMS considers treatment acute when “a patient is being treated for a new injury, identified by x-ray or physical exam. . . . The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.”

Chronic Treatment

CMS considers treatment chronic when the patient’s condition is “not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the 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 objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.”

Maintenance Therapy

CMS considers treatment maintenance therapy when the therapy in question “is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.”

Medical Necessity for Chiropractic Adjustment According to Medicare

“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of FUNCTION.”