Dynamic Chiropractic – January 15, 2006, Vol. 24, Issue 02

Medicare Regulations and Limits on Care

By Samuel A. Collins

Q: I have heard conflicting in formation on visit limitations on Medicare. Is it still 12 visits?

A: Medicare does not have a specified number of visits it will cover.

In other words, a patient is not automatically afforded 12 or any specific number of visits. Medicare will allow the number of visits necessary to effect improvement or arrest the patient's condition, within a reasonable and generally predictable period of time. Medicare also will pay for a flare-up of a chronic condition, so long as the doctor has demonstrated that there has been a functional improvement of the patient's condition. It is not uncommon for offices that document and code services properly to receive care plans for Medicare that exceed 30 visits per year.

Any limits are based on the severity and acuity of the specific condition (diagnosis) of the patient. Though the primary diagnosis for a Medicare patient must be subluxation, bear in mind that the secondary musculoskeletal diagnosis is what sets the parameters of care. If your diagnosis is of a low level (pain or symptom only), it likely will result in allowance of a limited number of visits. Conversely, if you have a high-level diagnosis such as disc injury or sciatica, there is an increased number of visits typically allowed. Other tertiary factors such as complicating conditions - spondylosis, scoliosis, kyphosis, etc. - will indicate a greater need for care as well. To maximize a Medicare beneficiary's benefit, you must diagnosis their condition to the highest level of specificity. Medicare publishes a list of diagnoses that are acceptable as secondary diagnoses of chiropractic claims; these diagnoses also are categorized under short-, moderate- and long-term care. For a copy of these codes, please e-mail a request to (noting that you read this article in DC), and I will forward a copy to you.

Samuel A. Collins
Santa Ana, California

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