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On January 15, 2001, the Centers for Medicare & Medicaid Services (CMS) declared that Medicare+Choice organizations "may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation." (See letter below.) The American Physical Therapy Association has responded with a letter seeking clarification. The problem has arisen because in the early 1970s, Congress amended the Medicare law to include coverage for "manual manipulation of the spine to correct a subluxation of the spine . . . which has resulted in a neuromuscular condition for which such manipulation is appropriate." To enable payment, chiropractors held a consensus conference that produced a 7-page document defining 18 types of "subluxations," many of which are fancy terms for the minor degenerative changes that occur as people age and are not changed by chiropractic treatment. Despite the inherent absurdity, chiropractors got paid because the Social Security Administration believed that Congress had intended that they be paid.
The significance of the CMS letter is unclear. Scientific practitioners (medical doctors and physical therapists) define "subluxation" as incomplete or partial dislocation -- a condition in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. No such condition can be corrected by chiropractic treatment. The vast majority of chiropractors use the term to mean other things. Some describe subluxations as "bones out of place" and/or "pinched nerves"; some think in terms of "fixations" or loss of joint mobility; and some occupy a middle ground that includes any or all of these concepts. Physical therapists are justified in seeking to preserve their right to perform manual manipulation to relieve back and neck discomfort. They do not actually treat any type of subluxation. However, it remains to be seen whether the semantic tangle created by the Medicare law will be used to restrict them.
CENTERS FOR MEDICARE & MEDICAID SERVICES
OPERATIONAL POLICY LETTER #23