A chiropactor may bill for manipulation under anethesia services – but you knew that already

Legal Update: DFS’s April 2019 ground-rule changes restrict cross-schedule coding by chiropractors. Giugliano’s 2010 trial result does not determine reimbursement under those later rules.

Last reviewed: September 2026

Giugliano v. Merchants Mutual awarded a chiropractor judgment after a 2010 trial over manipulation-under-anesthesia billing. The court heard competing testimony, including the treating doctor’s rebuttal. That record-specific result is not authority to use the same cross-specialty codes under later fee schedules.

A trial result under the older schedule

The Giugliano opinion discusses CPT 22505 and 21451, the services performed and the doctors’ respective roles. The parties had stipulated to threshold issues, but the court still weighed the trial evidence. Jason’s view that a trial or rebuttal witness was unnecessary should not be mistaken for the court’s account of what it decided.

The opinion does not cite the agency letter reproduced in the original commentary. That letter has not been independently obtained for this review; its quoted conversion-factor comparison is not presented as a current rate.

DFS identifies ground rules effective April 1, 2019 that prohibit chiropractors from using codes outside their own schedule. Check the service date before relying on the older cross-schedule analysis. This does not establish that every MUA service is unreimbursable, and the post is not medical advice about whether to undergo the procedure.

Jason’s historical commentary

Jason’s original commentary, including his quoted account of the 2009 agency letter, is retained as a historical record. The letter itself remains unverified here. The quoted percentage, litigation predictions and broad billing proposition are not current schedule advice; the court’s trial findings and later rules are explained above:

A Civil Court in a published decision rebuked an ill-fated, ill-conceived and senseless challenge to the proposition that a chiropractor may perform and bill for MUA services.

John Giugliano, DC, P.C. v Merchants Mut. Ins. Co., 2010 NY Slip Op 20308 (Civ. Ct. Kings Co. 2010)

While I might have my own personal misgivings about the MUA procedure and how it is being performed in the no-fault world, a chiropractor may bill for it.  I can discuss here how some of the MUA procedures I see being done should be reported to the Department of Education or OPM.  Yet, that is not the purpose of this discussion.

The reason why the defense practitioner in this case was way off the mark in defending this matter, is based upon an opinion letter, dated 8/14/09 from the general counsel of the Workers’ Compensation Board, Kenneth J. Munnelly, which says this:

“For example, if an appropriately trained chiropractor performs MUA, then that chiropractor can bill under the pertinent codes.  The CPT Codes most commonly billed under are 22505 and 27275. The relative value unit (RVU) is established for such CPT codes by the official medical fee schedule and remains constant whether a medical doctor, osteopathic doctor or chiropractor bills for that service using that code. The reimbursement rate, however, differs based upon the conversion factor assigned to the type of provider. The comparison of conversion factors that an osteopathic doctor would bill versus the factor under which a chiropractor would bill indicates that the chiropractor should be billing and get paid at 68.4% of the allowable conversion factor for the medical and osteopathic doctors performing the same procedure.”

You can find this letter in various arbitration decisions, e.g., AAA # 412010007480.  I am still looking for a copy of the actual letter.

We can all agree, I think, that an opinion letter from the agency that is in charge of the fee schedule, which says that a chiropractor may bill for MUA services, ends the debate.

But I also have similar misgivings about why Plaintiff did not make a summary judgment motion, or even bothered calling a rebuttal witness at the trial in this matter.  The facts of this case did not present any factual issues; it involved an issue of law that was properly decided adversely to the insurance carrier.

I mean if an insurance carrier -justifably- can waive an opinion letter and create Fogel and Great Wall, then why is this any different?  The shoe was on the other foot in this case.  It happens.

Connect to the Encyclopedia

• Fee-schedule defense hub: cases, proof and later developments
• New Wave: dating the older acupuncture comparison rate
• Liberty Chiropractic: proof of the units and conversion factor
• Jodi Jacobs: applying the correct service codes
• Down-coding: the rule and evidence for a reduction

For review of a particular no-fault billing dispute, contact our office.