Guidelines for Emergency Room Chiropractic Reimbursement

I kid you not.  Read the excerpt, the the article (especially the clinical vignette included), then read my mea culpa at the end.  In that order please, no skipping around.   Emphasis mine:

Guidelines for Emergency Room Chiropractic Reimbursement

It is crucial that those involved in clinical case management, both in the hospital and the insurance industry, be familiar with the appropriateness and indications for chiropractic care in the hospital setting. In 1987, the American College of Surgeons published a position paper that approved of the association with chiropractors in the hospital setting. Their statement read, in part, as follows:

In my six-plus years of being on-call in the hospital emergency department (ED), I have seen numerous ED physicians gain familiarity with the indications for chiropractic consultation. I have enjoyed seeing the attending physicians learn to appreciate the role of the chiropractor in the ED. Even more enjoyable is witnessing the ED physician’s growing dependence on their staff of chiropractors.

The following case history illustrates an example of an ED patient whose insurance company denied reimbursement until receiving further explanation…

This case involved a woman suffering from a severe and disabling headache. The attending ED physician evaluated her condition. She discovered that the patient had a long history of migraine headaches, for which she had been under the care of a neurologist. For the past week, the patient had suffered progressively worse headaches that were not relieved by numerous prescriptions or over-the-counter medications. The ED attending physician had to consider co-morbidities and other risk factors, including the patient’s history of a previous CVA. After obtaining the appropriate imaging studies, the attending diagnosed the patient as suffering from migraine with cervical tension cephalgia characteristics. The patient had already self-medicated with Imitrex at home. The attending first ordered administration of Toradol, a potent nonsteroidal anti-inflammatory drug. When Toradol did not relieve the patient, the attending ordered Demerol, a strong narcotic analgesic. When Demerol failed to provide relief, the attending had to consider additional treatment options.

I’m here to confess myself a sinner.  I have referred patients for chiropractic care (while in the military, on Active Duty).  I can explain.

In my ‘practice’, involving only adult males in excellent physical condition with an average age of 21 (Marines and Sailors) there were always a few who had acute and occasionally chronic neck and or lower back pain.  As these excellent specimens of the human form had to routinely hump packs of 80 plus pounds for miles, and wear a helmet heavier than their head while doing so, I wasn’t really surprised. 

I was surprised that they, and our mutual Commanding Officer, expected them to be completely well and 100% with a day or two of Motrin (they called me King Motrin on the boat, and I carried a full bottle with me for those who presented in the passageways with “…and it hurts”, getting some Motrin from me) and light duty, and it quickly became obvious that a) Base Hospital Physical Therapy was a lot more interested in post-op patients and their schedules were full, b) the CO expects me to Do Something, and c) there’s this new Chiropractic service opening up, and they have a lot of slots and are advertising for troops with back pain.  No-brainer.  Off go the consults, and then if they aren’t quickly returned to duty, it’s no longer on me.  Sorry, that’s how it worked.

I do not anticipate becoming dependent on chiropractic consults in my ED practice for a while.  And I cannot keep up with my own billing, let alone theirs.


  1. I’ve also found a lot of people with constant “migraine” headaches whereby Immitrex, narcotics and NSAIDS are not working are really having “rebound headaches”. My sister, who suffered from just such a headache merry-go-round didn’t believe me about hte existence of rebound headaches. But she reluctantly tried my suggestion of weaning herself from pain meds. After three days of misery, she was headache free. It worked. Now, she only gets the ocasional “real” migraine, around her menstrual cycle, for which Immitrex DOES now work. (I know this doesn’t cover everybody, but it is a thought to consider for some people with lots of headaches….)

  2. As a practicing San Francisco chiropractor for 15 years, I can’t imagine myself in the emergency room. I do receive plenty of medical referrals, but they are to my clinic after the patient has been checked out medically. Sure, some of these patients have nothing more than a simple sprain and should have gone straight to the chiropractor, but for the most part, there is no harm done. This works in reverse as well. If I feel something is beyond my scope of practice I refer out for medical attention. All this without the emergency room.

  3. Doc,
    I just stumbled upon this (over a year later). I am a DC who may very soon be working in a hospital setting on an army base – working with active duty personnel. Any suggestions? It is my dream to work under an MD’s orders in such a capacity, helping out within our scope! I am against the quacks in our profession, who bring the rest of us down.


  4. If I feel something is beyond my scope of practice I refer out for medical attention. All this without the emergency room.