3427 CMS May Eliminate X-Ray Reimbursement on Referral
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Dynamic Chiropractic – August 27, 2007, Vol. 25, Issue 18

CMS May Eliminate X-Ray Reimbursement on Referral

How Would It Affect Your Practice?

By Editorial Staff

"The current X-ray Medicare protocol has served patients well, and there is no clinical reason for the proposed change."

- ACA President Richard Brassard, DC

image - Copyright – Stock Photo / Register Mark The Centers for Medicare & Medicaid Services (CMS) has proposed eliminating reimbursement for X-rays taken for a doctor of chiropractic by a radiologist or other non-treating physician.

The proposed rule change, published in the Federal Register, would effectively reverse a long-standing CMS policy regarding X-ray reimbursement. The July 12 notification in the technical corrections section of the Federal Register explains the background and details of the proposed change:

Section 1861(r)(5) of the Act was amended by section 4513(a) of the BBA [Balanced Budget Act] to allow Medicare payment for a chiropractor's manual manipulation of the spine to correct subluxation, without requiring the subluxation to be demonstrated by an X-ray. The BBA provision was effective for services furnished on or after January 1, 2000. Prior to this statutory change, the subluxation was required to be demonstrated by an X-ray. Because chiropractors are limited by statute with respect to the services they can provide under Medicare, it had been necessary to create an exception to the requirement that diagnostic services (including X-rays) must be ordered by the treating physician as provided in section 410.32(a). This exception, which permits a physician who is not a treating physician to order and receive payment for an X-ray that is used by a chiropractor, is specified in section 410.32(a)(1).

We revised section 410.22 to reflect the BBA change in the CY 2000 PFS final rule (64 FR 59439). (Note: section 410.22 was redesignated as section 410.21 in the CY 2001 PFS final rule.) However, we neglected to remove the chiropractic exception at section 410.32 (a)(1). Because of the BBA change, which removed the requirement that subluxation must be demonstrated by an X-ray, the chiropractic exception is no longer warranted. We do not believe it would be necessary or appropriate to continue to permit payment for an X-ray ordered by a nontreating physician when a chiropractor, not the ordering physician, will use that X-ray. Therefore, we are proposing to revise section 410.32 by removing paragraph (a)(1) and by redesignating paragraphs (a)(2) and (a)(3) as (a)(1) and (a)(2), respectively.

According to section 410.32, as currently written, "A physician may order an X-ray to be used by a chiropractor to demonstrate the subluxation of the spine that is the basis for a beneficiary to receive manual manipulation treatments even though the physician does not treat the beneficiary."

"X-rays, when needed, are integral to the overall chiropractic treatment plan of Medicare patients, and unfortunately, in the end, it is the beneficiary who will be negatively affected by this proposed change in coverage," said Richard Brassard, DC, president of the American Chiropractic Association (ACA). "If doctors of chiropractic are unable to refer patients directly to a radiologist, patients may be required to make additional and unnecessary visits to their primary care providers, significantly driving up the costs of patient care."

It is important to note that the rule change, if adopted, would specifically impact reimbursement in connection with referral from a doctor of chiropractic to a nontreating physician/radiologist for X-rays; doctors of chiropractic would be allowed to backrefer patients to any treating physician, such as a primary care provider, for X-rays.

CMS is accepting comments regarding the proposed rule change until Aug. 31. The ACA plans on submitting an official comment prior to the Aug. 31 deadline, and is urging doctors of chiropractic to do the same. In a sample letter posted on its Web site, the ACA states:

  • While subluxation does not need to be detected by X-ray, in some cases the patient will require one clinically to identify a subluxation, to rule out any "red flags" or to determine diagnosis and treatment options.
  • X-rays also may be required to determine the need for further diagnostic testing, such as MRI or for a referral to the appropriate specialist.
  • By limiting doctors of chiropractic from referring X-rays, the costs to Medicare patients will increase due to the necessity of a referral to a specialist (orthopedist, rheumatologist, etc.) prior to referral to a radiologist.
  • With fixed incomes and limited resources, Medicare patients may choose to forgo X-rays, rather than pay for them out of pocket, and thus not receive needed treatment.

"The current X-ray Medicare protocol has served patients well, and there is no clinical reason for the proposed change," said Dr. Brassard, summing up the ACA stance on the issue.

For specific information on how to submit a comment to CMS, contact the ACA Office of Government Relations at (703) 812-0224 or .


  1. Proposed Rules: Diagnostic X-ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions. Federal Register, July 12, 2007. Vol. 72, No. 133.
  2. "CMS Proposes Changes to Chiropractic X-ray Reimbursement." American Chiropractic Association, July 31, 2007.

Dynamic Chiropractic editorial staff members research, investigate and write articles for the publication on an ongoing basis. To contact the Editorial Department or submit an article of your own for consideration, email .

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