Consent of Understanding

The government's Medicare program offers limited coverage for services provided by Doctors of Chiropractic (DCs). The coverage is limited to manual manipulation for the treatment of subluxation. If your required Chiropractic Adjustment (manipulation treatment) complies with Medicare's guidelines, it is typically covered. Medicare services fall into three categories:

1. Non-covered,

2. Always covered

3. Potentially covered.

NON-COVERED

All services other than manual manipulation of the spine for treatment of subluxation of the spine are excluded when ordered or performed by a Doctor of Chiropractic. Chiropractors are not required to bill these to Medicare. Chiropractic offices may want to submit charges to Medicare to obtain a denial necessary for submitting to a secondary insurance carrier. We hope that one day, the U.S. Congress will amend this and grant Chiropractors the same treatment as other medical professionals. The following are examples (not an all-inclusive list) of services that, when performed by a Chiropractor, are excluded from Medicare coverage:

Examples of Non-Covered Services

1. All Services Other than Chiropractic Adjustments:

   • Office Visits- to evaluate and manage, re-evaluate, advise, or counsel.

   • Physiotherapy- such as massage, traction, electrical stimulation, neuromuscular re-education, etc.

   • X-rays, Laboratory, Supplies, Vitamins, etc.

2. Various Chiropractic Adjustments:

   • Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage, and abdomen.

   • Once the maximum therapeutic benefit for a given condition has been achieved, ongoing Maintenance Care/Therapy is not medically necessary under the Medicare program.

   • Wellness Care- to promote better health.

NON-Covered items will appear on your insurance claim form.

They will appear as a Medicare NON-Covered service, denoted as “72010-GY.” The “72010” code refers to an x-ray, while the “–GY” modifier indicates non-coverage, allowing the service to be processed through the Medicare system. Once Medicare denies the claim, it can then be submitted to your secondary insurance. If you have Medigap insurance (also known as Medicare Secondary or Supplemental insurance), coverage will be provided according to the terms of your contract/policy.

ALWAYS COVERED

A common example of a Medicare-covered service is when you experience significant pain due to a severe spinal condition. Medicare is also expected to cover and fund your rehabilitation as long as you show improvement. When you receive a covered chiropractic spinal adjustment (manipulation treatment), it will appear on your Medicare claim form and payment reports under the codes “98940”, “98941”, or “98942”.

POTENTIALLY COVERED

According to Medicare guidelines, your chiropractic adjustment must be deemed clinically necessary. If Medicare determines that your condition is not "medically necessary," they will not cover the costs. Should we anticipate that Medicare might not pay for your chiropractic adjustment due to their regulations, we will inform you promptly. In addition, we will provide you with a special Medicare form known as the Advance Beneficiary Notice (ABN).

STATEMENT OF UNDERSTANDING

I acknowledge that I am personally and financially responsible for all services not covered by Medicare. I also understand that there may be instances when my chiropractic adjustments are not covered; in such cases, my doctor will inform me. Additionally, I am responsible for any annual deductibles or applicable copayments required by Medicare.

By signing below, I affirm my comprehension and acknowledgment of the Medicare information outlined in this form.