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 shall be applicable to the rules of the Iowa board of chiropractic.
“Active chiropractic physiotherapy” means therapeutic treatment performed by the patient with the assistance and guidance of the chiropractic assistant including, but not limited to, exercises and functional activities that promote strength, endurance, flexibility, and coordination.
“Acupuncture,” pursuant to Iowa Code section 148E.1, means a form of health care developed from traditional and modern oriental medical concepts that employs oriental medical diagnosis and treatment, and adjunctive therapies and diagnostic techniques, for the promotion, maintenance, and restoration of health and the prevention of disease.
“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. 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 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, which 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.
“Chiropractic assistant” means a person who has satisfactorily completed a 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.
“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.
“Passive chiropractic physiotherapy” means therapeutic treatment administered by the chiropractic assistant 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,” pursuant to Iowa Code section 148E.1, means the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body based upon oriental medical diagnosis as a primary mode of therapy. Adjunctive therapies within the scope of acupuncture may include manual, mechanical, thermal, electrical, and electromagnetic treatment, and the recommendation of dietary guidelines and therapeutic exercise based on traditional oriental medicine concepts.
“Supervising chiropractic physician” means the Iowa-licensed chiropractor responsible for supervision of services provided to a patient by a chiropractic assistant.
“Supervision” means the physical presence and direction of the supervising chiropractic physician at the location where services are rendered.
645—43.2(147,272C) Principles of chiropractic ethics. The following principles of chiropractic ethics are hereby adopted by the board relative to 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 which 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 which have the purpose of improving both the health and well-being of the individual and the community.
645—43.3(514F) Utilization and cost control review.
	43.3(1) The board shall establish utilization and cost control review (UCCR) committee(s). A UCCR committee shall be established by approval of the board upon a showing that the committee meets the requirements of this rule. The name of each committee and a list of committee members shall be on file with the board and available to the public. As a condition of board approval, each committee shall agree to submit to the board an annual report which meets the requirements of this rule.
	43.3(2) Each member of a UCCR committee shall:
	a. 	Hold a current license in Iowa.
	b. 	Have practiced chiropractic in the state of Iowa for a minimum of five years prior to appointment.
	c. 	Be actively involved in a chiropractic practice during the term of appointment as a UCCR committee member.
	d. 	Have no pending disciplinary action, no disciplinary action taken during the three years prior to appointment, and no disciplinary action pending or taken during the period of appointment.
	e. 	Have no malpractice judgment awarded or settlement paid during the three years prior to appointment or during the period of appointment.
	f. 	Not assist in the review or adjudication of claims in which the committee member may reasonably be presumed to have a conflict of interest.
	g. 	Rescinded IAB 5/10/06, effective 6/14/06.
	43.3(3) Procedures for utilization and cost control review. A request for review may be made to the UCCR committee by any person governed by the various chapters of Title XIII, subtitle 1, of the Iowa Code, self-insurers for health care benefits to employees, other third-party payers, chiropractic patients or licensees.
	a. 	There shall be a reasonable fee, as established by the UCCR committee and approved by the board, for services rendered, which will be made payable directly to the UCCR committee that conducts the review. Each UCCR committee approved by the board shall make a yearly accounting to the board.
	b. 	A request for service shall be submitted to the executive director of the UCCR committee on a submission form approved by the board, and shall be accompanied by the number of copies required by the UCCR committee.
	c. 	The UCCR committee shall respond in writing to the parties involved with its findings and recommendations within 90 days of the date the request for review was submitted. The committee shall review the appropriateness of levels of treatment and give an opinion as to the reasonableness of charges for diagnostic or treatment services rendered as requested.
	43.3(4) Types of cases reviewed shall include:
	a. 	Utilization.
	(1)	Frequency of treatment;
	(2)	Amount of treatment;
	(3)	Necessity of service;
	(4)	Appropriateness of treatment.
	b. 	Usual and customary service.
	43.3(5) Criteria for review may include but are not limited to:
	a. 	Was diagnosis compatible and consistent with information?
	b. 	Were X-ray and other examination procedures adequate, or were they insufficient or unrelated to history or diagnosis?
	c. 	Were clinical records adequate, complete, and of sufficient frequency?
	d. 	Was treatment consistent with diagnosis?
	e. 	Was treatment program consistent with scientific knowledge and with academic and clinical training provided in accredited chiropractic colleges?
	f. 	Were charges reasonable and customary for the service?
	43.3(6) Confidentiality. Members of the UCCR committee shall observe the requirements of confidentiality imposed by Iowa Code chapter 272C.
	43.3(7) Annual report. Each UCCR committee shall annually submit a report to the board, and shall meet to review that report with the board chairperson or designee upon the board’s request. The annual report shall include the following information:
	a. 	The fee to be charged the party requesting UCCR review.
	b. 	A report regarding the activities of the committee for the past year, including a report regarding each review conducted, the conclusions reached regarding that review, and any recommendations made following the review.
	43.3(8) A conclusion or recommendation, or both, made by a UCCR committee does not constitute a decision of the board.
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, shall notify the board annually that they are engaged in those activities and of the location where those activities are performed.
	43.4(3) Licensed chiropractic physicians shall 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.
645—43.5(151) Acupuncture. A chiropractic physician who engages in the practice of acupuncture shall 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 shall 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 shall provide the transcript or certification of completion to the board upon request.
[ARC 9109B, IAB 10/6/10, effective 11/10/10]
645—43.6(151) Nonprofit nutritional product sales. Rescinded IAB 11/26/03, effective 12/31/03.
645—43.7(151) Adjunctive procedures.
	43.7(1) Adjunctive procedures are defined as procedures related to differential diagnosis.
	43.7(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.
	43.7(3) Applicants for licenses to practice chiropractic who refuse to utilize any of the adjunctive procedures which 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.
645—43.8(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 shall not include prescription drugs or operative surgery.
645—43.9(151) Gonad shielding. Gonad shielding of not less than 0.25 millimeter lead equivalent shall be used for chiropractic patients who have not passed the reproductive age during radiographic procedures in which the gonads are in the useful beam, except for cases in which this would interfere with the diagnostic procedures.
645—43.10(151) Record keeping.
	43.10(1) Chiropractic physicians shall maintain clinical records in a manner consistent with the protection of the welfare of the patient. Records shall be timely, dated, chronological, accurate, signed or initialed, legible, and easily understandable. Record-keeping 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.
	43.10(2) Chiropractic physicians shall maintain clinical records for each patient. The clinical records shall, at a minimum, 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 shall 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 shall include the patient’s stated health concerns.
	d. 	Clinical examination progress notes. Records shall 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 shall include the patient’s name, the date information was recorded and the doctor’s name or facility’s name.
	43.10(3) Retention of records. A chiropractic physician shall maintain a patient’s record(s) for a minimum of six years after the date of last examination or treatment. Records for minors shall 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 shall be maintained to ensure the safety of records from destructive elements. This provision includes both clinical and fiscal records.
	43.10(4) Electronic record keeping. When electronic records are utilized, a chiropractic physician shall maintain either a duplicate hard-copy record or a backup electronic record.
	43.10(5) Correction of written records. Notations shall 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.
	43.10(6) Correction of electronic records. Any alterations made after the date of service shall be visibly recorded. All alterations shall 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.
	43.10(7) Abbreviations shall be standard and common to all health care disciplines. Nonstandard abbreviations shall be referenced with a key that is included in the record when the record is requested.
	43.10(8) Confidentiality and transfer of records. Chiropractic physicians shall preserve the confidentiality of patient records. Upon signed request of the patient, the chiropractic physician shall furnish such records or copies of the records as directed by the patient within 30 days. A notation indicating the items transferred, date and method of transfer shall 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. 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.
	43.10(9) Retirement or discontinuance of practice. A licensee, upon retirement, discontinuation of the practice of chiropractic, leaving a practice, or moving from a community, shall:
	a. 	Notify all active patients, in writing and by publication, once a week for three consecutive weeks in a newspaper of general circulation in the community. The notification shall 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.
	c. 	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.
	43.10(10) Record-keeping procedures and standards shall be utilized for all individuals who receive treatment from a chiropractic physician in all sites where care is provided.
	43.10(11) A chiropractic physician who offers a prepayment plan for chiropractic services shall:
	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, shall include provisions that:
	(1)	Prepaid funds will not be expended until services are provided; and
	(2)	The patient shall receive a prompt refund of any unused funds upon request. The refund shall be calculated based on a defined method, which shall 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 9109B, IAB 10/6/10, effective 11/10/10]
645—43.11(151) Billing procedures.
	43.11(1) Chiropractic physicians shall maintain accurate billing records for each patient. Records may be stored on paper or electronically. The records shall 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.
	43.11(2) Chiropractic physicians shall preserve the confidentiality of billing records.
	43.11(3) Upon signed request of the patient, the chiropractic physician shall 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 fees.
	43.11(4) Each chiropractic physician is responsible for the accuracy and validity of billings submitted under the chiropractic physician’s name.
	43.11(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 which 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.
	43.11(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 shall 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.
	43.11(7) Chiropractic physicians shall 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 which 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 which misrepresents the nature of the chiropractic services that have been performed.
	43.11(8) For cases not involving third-party payers, nothing in this rule shall prevent a chiropractic physician from providing a fee reduction for reasonable time of service or substantiated hardship cases. The chiropractic physician shall document time of service or hardship case fee reduction provisions in the patient record.
	43.11(9) The chiropractic physician shall 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 shall document any hardship case fee reduction provisions in the patient record.
645—43.12(151) Chiropractic assistants. The requirements of this rule shall become effective on July 1, 2009.
	43.12(1) Supervisory responsibilities of the chiropractic physician.
	a. 	The supervising chiropractic physician shall ensure at all times that the 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 chiropractic assistant that are within the scope of practice of the chiropractic physician in a manner consistent with these rules. Violation of these rules shall be grounds for discipline under 645—Chapter 45.
	c. 	A chiropractic physician shall not delegate to the 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 shall ensure that a chiropractic assistant is informed of the supervisor and chiropractic assistant relationship and is responsible for all services performed by the chiropractic assistant.
	43.12(2) Education requirements for chiropractic assistants.
	a. 	The supervising chiropractic physician shall ensure that a chiropractic assistant has completed a chiropractic assistant training program. A chiropractic assistant training program shall include training and instruction on the use of chiropractic physiotherapy procedures related to services to be provided by the chiropractic assistant. Any chiropractic assistant training program shall be provided by an approved CCE-accredited chiropractic college or a chiropractic state association.
	b. 	Chiropractic assistants performing active chiropractic physiotherapy procedures are required to complete 12 hours of instruction, of which 6 hours shall be clinical experience under the supervision of the chiropractic physician.
	c. 	Chiropractic assistants performing passive chiropractic physiotherapy procedures are required to complete 12 hours of instruction, of which 6 hours shall be clinical experience under the supervision of the chiropractic physician.
	d. 	If both paragraphs “b” and “c” apply, then 12 hours of instruction for active chiropractic physiotherapy procedures and 12 hours of instruction for passive chiropractic physiotherapy procedures shall be required for a total of 24 hours of instruction.
	e. 	The supervising chiropractic physician shall provide a written attestation to the chiropractic college that the chiropractic assistant has completed the clinical experience. The college shall 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 shall maintain in the chiropractic physician's primary place of business proof of the chiropractic assistant's completion of the training program. Copies of such documents shall be provided to the board upon request.
[ARC 0006C, IAB 2/8/12, effective 3/14/12]
These rules are intended to implement Iowa Code chapter 151.
[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]