Chiropractic imaging under Medicare attracts attention

Aug 22, 2005

Under a new Medicare policy, radiologists in some states can now be reimbursed for CT and MR scans ordered by chiropractors. However, the American College of Radiology (ACR) has raised caution flags over the concept, and imaging centers elsewhere can run into problems if they submit claims for chiropractic-related imaging.

But thanks to a demonstration project that began on April 1, Medicare's policy on chiropractic imaging is now literally all over the map. Chiropractors in Maine, New Mexico, and parts of Illinois, Iowa, and Virginia can now order reimbursable CTs and MRIs for Medicare patients.

Chiropractors in those locations can also now get reimbursement from Medicare for x-rays they themselves obtain and interpret. While this change represents a new opportunity for self-referred imaging by chiropractors, the prospect didn't raise any red flags for Dr. David Levin, one of the leading researchers in imaging utilization.

"Any time you allow people to self-refer, it's obviously always a concern," said Levin, a researcher at Thomas Jefferson University in Philadelphia. "But I think that chiropractic x-ray is probably a relatively small piece of the pie in terms of overall utilization."

The two-year demonstration project, which may lead to nationwide changes in Medicare policies toward chiropractic care, is the result of federal legislation sponsored by Sen. Charles Grassley (R-Iowa), whose state includes the founding Palmer College of Chiropractic.

But outside of the demonstration areas, imaging centers that mistakenly bill Medicare for scans ordered by chiropractors can still get into trouble for doing so.

In July, federal auditors recommended that an imaging center in the InSight Health chain refund $88,747 to the government for chiropractor-ordered services. In their report, officials stated that Garfield Imaging Center in Monterey Park, CA, lacked "adequate controls to prevent billing Medicare for diagnostic services ordered by chiropractors."

There has also been some confusion over claims in regions where reimbursement is now authorized, according to Dr. Ritch Miller, a Nebraska chiropractor and chairman of the Medicare committee for the American Chiropractic Association.

The bulk of the reported problems involve incorrectly coded claims, along with clearinghouse confusion and inappropriate denials by local carriers, Miller said.

More notable is what Miller hasn't heard thus far: There have been no complaints from chiropractors in the project areas about radiologists generally refusing to work with them.

Individual radiology practices may still be declining to work with chiropractors. But today's situation represents a sea change from prevailing attitudes decades ago, when the American Medical Association and other groups, including the ACR, advised members that it was unethical to deal with chiropractors.

Past ostracism of chiropractors contributed to the development of chiropractic radiologists, who spend a minimum of three years in residencies to become diplomates of the American Chiropractic Board of Radiology (ACBR). While these practitioners won't be paid for reading CT and MR scans under the Medicare project, they may well see an increase in their plain x-ray interpretation loads from the demo, according to Dr. Cliff Tao, a chiropractic radiologist based in Orange County, CA.

Mainstream medical associations altered their positions on chiropractic care after being sued by chiropractors in 1976 in a long-running antitrust lawsuit that was finally settled in the early 1990s.

"The ACR's policy now is that radiologists are free to make their own decision about whether or not or to what extent they will work in conjunction with chiropractors," said attorney William Shields, the college's general counsel, in a recent interview with AuntMinnie.com.

But the ACR has also advised its members to carefully weigh their participation in the Medicare demonstration project, citing liability concerns.

"The problem is what happens when there's a positive result on the film," Shields noted. "Will the radiologist be considered the only physician in the loop on this -- and therefore liable if the patient is not informed -- if the chiropractor has the report but does not pass it on to the patient?"

Similar issues have been raised by the New York State Radiological Society (NYSRS), which questioned whether members should avail themselves of Medicare policies allowing radiologists to order and be reimbursed for x-rays on chiropractors' patients.

"Some radiologists are concerned that ordering an x-ray will impose upon them some legal and/or ethical responsibility as a physician of record, that responsibility being some duty to assure that the patient whose image indicates the need for medical follow-up actually receives such follow-up care," notes the society's Web site.

Since there are no specific laws or regulations governing responsibility for the findings in imaging for chiropractors, these questions will likely ultimately be resolved in the courts or by state medical authorities, Shields said.

In the meantime, chiropractor Miller thinks concerns about liability are overblown, and that many radiologists are already comfortable working with chiropractors like him who have ordered scans on patients with private or self-paid healthcare coverage.

While x-rays are primarily used to identify the spinal subluxations that chiropractors are trained to work on, Miller says he requests around four CTs and MRIs a month, and that the patient's primary care physician is alerted to any findings that require follow-up.

In addition to enjoying the additional referrals, radiologists should work with chiropractors to help them stay within their scope of practice, Miller said.

"That's why you order a CT or MRI: to make sure that this is something you can address and that there isn't something else going on," he said.

By Tracie L. Thompson
AuntMinnie.com staff writer
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