CHAPTER 43
PRACTICE OF CHIROPRACTIC PHYSICIANS
[Prior to 7/24/02, see 645—40.1(151) and 645—40.17(151) to 645—40.24(147,272C)]
645—43.1(151) Definitions. The following definitions will be applicable to the rules of the Iowa board of chiropractic.
“Active chiropractic physiotherapy” means therapeutic treatment performed by the patient, including but not limited to exercises and functional activities that promote strength, endurance, flexibility, and coordination.
“Acupuncture” means the same as defined in Iowa Code section 148E.1.
“Adjustment/manipulation of neuromusculoskeletal structures” means the use by a doctor of chiropractic of a skillful treatment based upon differential diagnosis of neuromusculoskeletal structures and procedures related thereto by the use of passive movements with the chiropractic physician’s hands or instruments in a manipulation of a joint by thrust so the patient’s volitional resistance cannot prevent the motion. The manipulation is directed toward the goal of restoring joints to their proper physiological relationship of motion and related function, or stimulation of joint receptors. Movement of the joint is by force beyond its active limit of motion, but within physiologic integrity. Adjustment or manipulation commences where mobilization ends and specifically begins when the elastic barrier of resistance is encountered by the doctor of chiropractic and ends at the limit of anatomical integrity. Adjustment or manipulation as described in this definition is directed to the goal of the restoration of joints to their proper physiological relationship and associated functions of motion and related function, release of adhesions or stimulation of joint receptors. Adjustment or manipulation as described in this definition is by hand or instrument. The primary emphasis of this adjustment or manipulation is upon specific joint element adjustment or manipulation and treatment of the articulation and adjacent tissues of the neuromusculoskeletal structures of the body and nervous system, using one or more of the following:
	1.	Impulse adjusting or the use of sudden, high velocity, short amplitude thrust of a nature that patient volitional resistance is overcome, commencing where the motion encounters the elastic barrier of resistance and ending at the limit of anatomical integrity.
	2.	Instrument adjusting, utilizing instruments specifically designed to deliver sudden, high velocity, short amplitude thrust.
	3.	Light force adjusting, utilizing sustained joint traction or applied directional pressure, or both, that may be combined with passive motion to restore joint mobility.
	4.	Long distance lever adjusting, utilizing forces delivered at some distance from the dysfunctional site and aimed at transmission through connected structures to accomplish joint mobility.
“Anatomic barrier” means the limit of motion imposed by anatomic structure, the limit of passive motion.
“CCCA” means the Certified Chiropractic Clinical Assistant program offered by the FCLB.
“Certified chiropractic assistant” means a person who has completed a certified chiropractic assistant training program to perform selected chiropractic health care services under the supervision of a chiropractic physician.
“Chiropractic insurance consultant” means an Iowa-licensed chiropractic physician registered with the board who serves as a liaison and advisor to an insurance company.
“Chiropractic manipulation” means care of an articular dysfunction or neuromusculoskeletal disorder by manual or mechanical adjustment of any skeletal articulation and contiguous articulations.
“Differential diagnosis” means to examine the body systems and structures of a human subject to determine the source, nature, kind or extent of a disease, vertebral subluxation, neuromusculoskeletal disorder or other physical condition, and to make a determination of the source, nature, kind, or extent of a disease or other physical condition.
“Elastic barrier” means the range between the physiologic and anatomic barrier of motion in which passive ligamentous stretching occurs before tissue disruption.
“Extremity manipulation” means a corrective thrust or maneuver by a doctor of chiropractic by hand or instrument based upon differential diagnosis of neuromusculoskeletal structures applied to a joint of the appendicular skeleton.
“FCLB” means the Federal Chiropractic Licensing Board.
“Malpractice” means any error or omission, unreasonable lack of skill, or failure to maintain a reasonable standard of care by a chiropractic physician in the practice of the profession.
“Mobilization” means movement applied singularly or repetitively within or at the physiological range of joint motion, without imparting a thrust or impulse, with the goal of restoring joint mobility.
“PACE” means Providers of Approved Continuing Education and is the signature program of the FCLB.
“Passive chiropractic physiotherapy” means therapeutic treatment administered and received by the patient, including but not limited to mechanical, electrical, thermal, or manual methods.
“Physiologic barrier” means the limit of active motion, which can be altered to increase range of active motion by warm-up activity.
“Practice of acupuncture” means the same as defined in Iowa Code section 148E.1.
“Supervising chiropractic physician” means the Iowa-licensed chiropractor responsible for supervision of services provided to a patient by a certified chiropractic assistant.
“Supervision” means the physical presence and direction of the supervising chiropractic physician at the location where services are rendered.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.2(147,272C) Principles of chiropractic ethics. The following principles of chiropractic ethics are adopted by the board for the practice of chiropractic in this state.
	43.2(1) These principles are intended to aid chiropractic physicians individually and collectively in maintaining a high level of ethical conduct. These are standards by which a chiropractic physician may determine the propriety of the chiropractic physician’s conduct in the chiropractic physician’s relationship with patients, with colleagues, with members of allied professions, and with the public.
	43.2(2) The principal objective of the chiropractic profession is to render service to humanity with full respect for the dignity of the person. Chiropractic physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion.
	43.2(3) Chiropractic physicians should strive continually to improve chiropractic knowledge and skill, and should make available to their patients and colleagues the benefits of their professional attainments.
	43.2(4) A chiropractic physician should practice a method of healing founded on a scientific basis, and should not voluntarily associate professionally with anyone who violates this principle.
	43.2(5) The chiropractic profession should safeguard the public and itself against chiropractic physicians deficient in moral character or professional competence. Chiropractic physicians should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed disciplines. They should expose, without hesitation, illegal or unethical conduct of fellow members of the profession.
	43.2(6) A chiropractic physician may choose whom to serve. In an emergency, however, services should be rendered to the best of the chiropractic physician’s ability. Having undertaken the case of a patient, the chiropractic physician may not neglect the patient; and, unless the patient has been discharged, the chiropractic physician may discontinue services only after giving adequate notice.
	43.2(7) A chiropractic physician should not dispose of services under terms or conditions that tend to interfere with or impair the free and complete exercise of professional judgment and skill or tend to cause a deterioration of the quality of chiropractic care.
	43.2(8) A chiropractic physician should seek consultation upon request, in doubtful or difficult cases, or whenever it appears that the quality of chiropractic service may be enhanced thereby.
	43.2(9) A chiropractic physician may not reveal the confidences entrusted in the course of chiropractic attendance, or the deficiencies observed in the character of patients, unless required to do so by law or unless it becomes necessary in order to protect the welfare of the individual or of the community.
	43.2(10) The honored ideals of the chiropractic profession imply that the responsibilities of the chiropractic physician extend not only to the individual, but also to society where these responsibilities deserve interest and participation in activities that have the purpose of improving both the health and well-being of the individual and the community.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.3  Reserved.
645—43.4(151) Chiropractic insurance consultant.
	43.4(1) A chiropractic insurance consultant advises insurance companies, third-party administrators and other similar entities of Iowa standards of:
	a. 	Recognized and accepted chiropractic services and procedures permitted by the Iowa Code and administrative rules, and
	b. 	The propriety of chiropractic diagnosis and care.
	43.4(2) All licensees who review chiropractic records for the purposes of determining the adequacy or sufficiency of chiropractic treatments, or the clinical indication for those treatments, will indicate on their licensure renewals that they are engaged in those activities and the location where those activities are performed.
	43.4(3) Licensed chiropractic physicians will not hold themselves out as chiropractic insurance consultants unless they meet the following requirements:
	a. 	Hold a current license in Iowa.
	b. 	Have practiced chiropractic in the state of Iowa during the immediately preceding five years.
	c. 	Are actively involved in a chiropractic practice during the term of appointment as a chiropractic insurance consultant. Active practice includes but is not limited to maintaining an office location and providing clinical care to patients.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.5(151) Acupuncture. A chiropractic physician who engages in the practice of acupuncture will maintain documentation that shows the chiropractic physician has successfully completed a course in acupuncture consisting of at least 100 hours of traditional, in-person classroom instruction with the instructor on site. The licensee will maintain a transcript or certification of completion showing the licensee’s name, school or course sponsor’s name, date of course completion or graduation, grade or other evidence of successful completion, and number of course hours. The licensee will provide the transcript or certification of completion to the board upon request.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.6(151) Adjunctive procedures.
	43.6(1) Adjunctive procedures are defined as procedures related to differential diagnosis.
	43.6(2) For any applicant for licensure to practice chiropractic in the state of Iowa who chooses to be tested in limited adjunctive procedures, those limited procedures must be adequate for the applicant to come to a differential diagnosis in order to pass the examination.
	43.6(3) Applicants for licenses to practice chiropractic who refuse to utilize any of the adjunctive procedures that they have been taught in approved colleges of chiropractic must adequately show the board that they can come to an adequate differential diagnosis without the use of adjunctive procedures.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.7(151) Physical examination. The chiropractic physician is to perform physical examinations to determine human ailments, or the absence thereof, utilizing principles taught by chiropractic colleges. Physical examination procedures will not include prescription drugs or operative surgery.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.8(151) Recordkeeping.
	43.8(1) Chiropractic physicians will maintain clinical records in a manner consistent with the protection of the welfare of the patient. Records will be timely, dated, chronological, accurate, signed or initialed, legible, and easily understandable. Recordkeeping rules apply to all patient records whether handwritten, typed or maintained electronically. Electronic signatures are acceptable when the record has been reviewed by the physician whose signature appears on the record.
	43.8(2) Chiropractic physicians will maintain clinical records for each patient, which include all of the following:
	a. 	Personal data.
	(1)	Name;
	(2)	Date of birth;
	(3)	Address; and
	(4)	Name of parent or guardian if a patient is a minor.
	b. 	Health history. Records will include information from the patient or the patient’s parent or guardian regarding the patient’s health history.
	c. 	Patient’s reason for visit. When a patient presents with a chief complaint, clinical records will include the patient’s stated health concerns.
	d. 	Clinical examination progress notes. Records will include chronological dates and descriptions of the following:
	(1)	Clinical examination findings, tests conducted, a summary of all pertinent diagnoses, and updated health assessments;
	(2)	Plan of intended treatment, including description of treatment, frequency and duration;
	(3)	Services rendered and any treatment complications;
	(4)	All testing ordered or performed;
	(5)	Diagnostic imaging report if imaging procedure is ordered or performed;
	(6)	Sufficient data to support the recommended treatment plan.
	e. 	Clinical record. Each page of the clinical record will include the patient’s name, the date information was recorded and the doctor’s name or facility’s name.
	43.8(3) Retention of records. A chiropractic physician will maintain a patient’s record(s) for a minimum of six years after the date of last examination or treatment. Records for minors will be maintained for one year after the patient reaches the age of majority (18) or six years after the date of last examination or treatment, whichever is longer. Proper safeguards will be maintained to ensure the safety of records from destructive elements. This provision includes both clinical and fiscal records.
	43.8(4) Electronic recordkeeping. When electronic records, which include both electronically created records and scanned paper records, are utilized, a chiropractic physician will maintain either a duplicate hard-copy record or a backup electronic record.
	43.8(5) Correction of written records. Notations will be legible, written in ink, and contain no erasures or whiteouts. If incorrect information is placed in the record, it must be crossed out with a single nondeleting line. Entries recorded at a time other than the date of the patient encounter must include the date of the entry and the initials of the author.
	43.8(6) Correction of electronic records. Any alterations made after the date of service will be visibly recorded. All alterations will include a notation setting forth the date of alteration and identification of the author. Entries recorded at a time other than the date of the patient encounter must include the date of the entry and the initials of the author.
	43.8(7) Abbreviations will be standard and common to all health care disciplines. Nonstandard abbreviations will be referenced with a key that is included in the record when the record is requested.
	43.8(8) Confidentiality and transfer of records. Chiropractic physicians will preserve the confidentiality of patient records. Upon signed request of the patient, the chiropractic physician will furnish such records or copies of the records as directed by the patient within 30 days. A notation indicating the items transferred, date of transfer and method of transfer will be maintained in the patient record. The chiropractic physician may charge a reasonable fee for duplication of records but may not refuse to transfer records for nonpayment of any fees. A written request may be required before the transfer of the record(s), including, for example, compliance with HIPAA regulations. In certain instances, a summary of the record may be more beneficial for the future treatment of the patient; however, if a third party requests copies of the original documentation, that request must be honored.
	43.8(9) Retirement or discontinuance of practice. A licensee, upon retirement, discontinuation of the practice of chiropractic, leaving a practice, or moving from a community, will:
	a. 	Notify all active patients, in writing one month prior to discontinuation of practice. The notification will include the following information:
	(1)	That the licensee intends to discontinue the practice of chiropractic in the community and that patients are encouraged to seek the services of another licensee; and
	(2)	How patients can obtain their records, including the name and contact information of the records custodian.
	b. 	Make reasonable arrangements with active patients for the transfer of patient records, or copies of those records, to the succeeding licensee.
For the purposes of this subrule, “active patient” means a person whom the licensee has examined, treated, cared for, or otherwise consulted with during the one-year period prior to retirement, discontinuation of the practice of chiropractic, leaving a practice, or moving from a community.
	43.8(10) Recordkeeping procedures and standards will be utilized for all individuals who receive treatment from a chiropractic physician in all sites where care is provided.
	43.8(11) A chiropractic physician who offers a prepayment plan for chiropractic services will:
	a. 	Have a written prepayment policy statement that is maintained in the office and available to patients upon request. The policy statement, at a minimum, will include provisions that:
	(1)	Prepaid funds will not be expended until services are provided; and
	(2)	The patient will receive a prompt refund of any unused funds upon request. The refund will be calculated based on a defined method, which will be clearly set forth in the written prepayment policy statement.
	b. 	Require the patient to sign and date a prepayment document that incorporates the conditions and descriptions of the written prepayment policy statement.
	c. 	Maintain the signed and dated written prepayment policy statement in the patient’s record.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.9(151) Billing procedures.
	43.9(1) Chiropractic physicians will maintain accurate billing records for each patient. Records may be stored on paper or electronically. The records will contain all of the following:
	a. 	Name, date of birth and address.
	b. 	Diagnosis indicated with description or ICD code.
	c. 	Services provided with description or CPT code.
	d. 	Dates of services provided.
	e. 	Charges for each service provided.
	f. 	Payments made for each service and indication of the party providing payment.
	g. 	Dates payments are made.
	h. 	Balance due for any outstanding charges.
	43.9(2) Chiropractic physicians will preserve the confidentiality of billing records.
	43.9(3) Upon signed request of the patient, the chiropractic physician will furnish billing records or copies of the records as directed by the patient within 30 days. The chiropractic physician may charge a reasonable fee for duplication of records, but may not refuse to transfer records for nonpayment of any outstanding balance.
	43.9(4) Each chiropractic physician is responsible for the accuracy and validity of billings submitted under the chiropractic physician’s name.
	43.9(5) Chiropractic physicians:
	a. 	Who are owners, operators, members, partners, shareholders, officers, directors, or managers of a chiropractic clinic will be responsible for the policies, procedures and billings generated by the clinic.
	b. 	Who provide clinical services are required to familiarize themselves with the clinic’s billing practices to ensure that the services rendered are accurately reflected in the billings generated. In the event an error occurs that results in an overbilling, the licensee must promptly make reimbursement of the overbilling whether or not the licensee is in any way compensated for such reimbursement by an employer, agent or any other individual or business entity responsible for such error.
	43.9(6) A chiropractic physician has a right to review and correct all billings submitted under the chiropractic physician’s name or identifying number(s). Signature stamps or electronically generated signatures will be utilized only with the authorization of the chiropractic physician whose name or signature is designated. Such authorization may be revoked at any time in writing by the chiropractic physician.
	43.9(7) Chiropractic physicians will not knowingly:
	a. 	Increase charges when a patient utilizes a third-party payment program.
	b. 	Report incorrect dates or types of service on any billing documents.
	c. 	Submit charges for services not rendered.
	d. 	Submit charges for services rendered that are not documented in a patient’s record.
	e. 	Bill patients or make claims under a third-party payer contract for chiropractic services that have not been performed.
	f. 	Bill patients or make claims under a third-party payer contract in a manner that misrepresents the nature of the chiropractic services that have been performed.
	43.9(8) For cases not involving third-party payers, nothing in this rule will prevent a chiropractic physician from providing a fee reduction for reasonable time of service or substantiated hardship cases. The chiropractic physician will document time of service or hardship case fee reduction provisions in the patient record.
	43.9(9) The chiropractic physician will not enter into an agreement to waive, abrogate, or rebate the deductible or copayment amounts of any third-party payer contract by forgiving any or all of any patient’s obligation for payment thereunder, except in substantiated hardship cases, unless the third-party payer is notified in writing of the fact of such waiver, abrogation, rebate, or forgiveness in accordance with the third-party payer contract. The chiropractic physician will document any hardship case fee reduction provisions in the patient record.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
645—43.10(151) Certified chiropractic assistants.
	43.10(1) Supervisory responsibilities of the chiropractic physician.
	a. 	The supervising chiropractic physician will ensure at all times that the certified chiropractic assistant has the necessary training and skills as required by these rules to competently perform the delegated services.
	b. 	The supervising chiropractic physician may delegate services to a certified chiropractic assistant that are within the scope of practice of the chiropractic physician in a manner consistent with these rules. Violation of these rules will be grounds for discipline under 645—Chapter 45.
	c. 	A chiropractic physician will not delegate to the certified chiropractic assistant the following:
	(1)	Services outside the chiropractic physician’s scope of practice;
	(2)	Initiation, alteration, or termination of chiropractic treatment programs;
	(3)	Chiropractic manipulation and adjustments;
	(4)	Diagnosis of a condition.
	d. 	A supervising chiropractic physician will ensure that a certified chiropractic assistant is informed of the supervisor and certified chiropractic assistant relationship and is responsible for all services performed by the certified chiropractic assistant.
	43.10(2) Education requirements for certified chiropractic assistants.
	a. 	The supervising chiropractic physician will ensure that a certified chiropractic assistant has completed a professional certification program. A certified chiropractic assistant training program will include training and instruction on the use of chiropractic physiotherapy procedures related to services to be provided by the certified chiropractic assistant. Any certified chiropractic assistant training program will be provided by an approved CCE-accredited chiropractic college, FCLB, PACE, CCCA, or a chiropractic state association.
	b. 	Certified chiropractic assistants performing active chiropractic physiotherapy procedures are required to complete 12 hours of instruction, of which 6 hours will be clinical experience under the supervision of the chiropractic physician.
	c. 	Certified chiropractic assistants performing passive chiropractic physiotherapy procedures are required to complete 12 hours of instruction, of which 6 hours will be clinical experience under the supervision of the chiropractic physician.
	d. 	If both paragraphs “b” and “c” of this subrule apply, then 12 hours of instruction for active chiropractic physiotherapy procedures and 12 hours of instruction for passive chiropractic physiotherapy procedures will be required for a total of 24 hours of instruction.
	e. 	The supervising chiropractic physician will provide a written attestation to the chiropractic college that the certified chiropractic assistant has completed the clinical experience. The college will issue a separate certificate of completion for the active or passive chiropractic training program as defined in paragraphs “b,”“c,” and “d” of this subrule.
	f. 	The chiropractic physician will maintain in the chiropractic physician’s primary place of business proof of the certified chiropractic assistant’s completion of the training program. Copies of such documents will be provided to the board upon request.
[ARC 7968C, IAB 5/15/24, effective 6/19/24]
These rules are intended to implement Iowa Code chapters 147, 151, 272C, and 514F.
[Filed 7/3/02, Notice 5/1/02—published 7/24/02, effective 8/28/02]
[Filed 11/6/03, Notice 7/23/03—published 11/26/03, effective 12/31/03]
[Filed 4/13/06, Notice 2/15/06—published 5/10/06, effective 6/14/06]
[Filed 1/28/08, Notice 11/7/07—published 2/27/08, effective 4/2/08]
[Filed 7/17/08, Notice 5/7/08—published 8/13/08, effective 9/17/08]
[Filed ARC 9109B (Notice ARC 8782B, IAB 6/2/10), IAB 10/6/10, effective 11/10/10]
[Filed ARC 0006C (Notice ARC 9885B, IAB 11/30/11), IAB 2/8/12, effective 3/14/12]
[Filed ARC 3956C (Notice ARC 3754C, IAB 4/25/18), IAB 8/15/18, effective 9/19/18]
[Filed ARC 7968C (Notice ARC 7465C, IAB 1/10/24), IAB 5/15/24, effective 6/19/24]