PURPOSE: This rule explains the professional conduct of licensed chiropractic physicians.

1. (1) Each licensed chiropractic physician shall notify the board of his/her business and residential address and telephone number(s) and immediately shall inform the board of any change of address or telephone number within fifteen (15) days of such change. Notification shall be sent to the board at 3605 Missouri Boulevard, or PO Box 672, Jefferson City, MO 65102-0672, contacting the board office at (573) 751-2104, or sending an email to chiropractic@pr.mo.gov.

2. (2) A chiropractic service may be considered routine for an individual practitioner if it has the following characteristics:

   1. (A) It is performed frequently in the doctor’s office;
   2. (B) It is usually provided at a set fee;
   3. (C) It is provided at little or no variance in technique; and
   4. (D) It includes all professionally recognized components within generally accepted standards.
3. (3) Each licensed chiropractic physician shall inform the board of anyone who may be practicing chiropractic in Missouri without a license.

4. (4) A chiropractic physician, when presenting him/herself to patients and the public, is directed to determine as far as is reasonably possible and consistent with chiropractic procedures—

   1. (A) The cause(s) of the patient’s abnormalities or deformities; and
   2. (B) Whether chiropractic treatments are reasonably likely to improve or assist in improving these abnormalities or deformities.

5. (5) A licensed chiropractic physician shall not—

   1. (A) Increase charges when a patient utilizes a third-party payment program; FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION
   2. (B) Report incorrect treatment dates for the purpose of obtaining payments;
   3. (C) Report charges for services not rendered; or
   4. (D) Report incorrectly services rendered for the purpose of obtaining greater payment than s/he is entitled to.

6. (6) Advertisement or Solicitation.

   1. (A) For the purpose of this rule, the terms “advertisement” and “solicitation” shall be defined as follows:

      1. 1. Advertisement—any form of public

notice, regardless of medium, using a licensee’s name, trade name or other professional designation of the licensee or chiropractic firm;

1. 2. Solicitation—any form of request or

plea, regardless of medium, used to entice or urge a person to use the services of a licensee or chiropractic firm;

1. 3. A licensee may advertise or solicit

through public media, such as a telephone directory, physician’s directory, newspaper or other periodical, outdoor billboard, radio, television, or through direct mail advertising or solicitation distributed generally to persons not known to need chiropractic care of the kind provided by the chiropractor, if such advertisement or solicitation is in accordance with this section;

1. 4. A licensee may initiate individual

written communications, not involving personal or telephone contact, to persons known or likely to need chiropractic care of the kind provided by the licensee. All such individual written communications to persons known or likely to need chiropractic care of the kind provided by the licensee shall be labeled at the top of the first page with the word “SOLICITATION” and shall contain the following notice:

SOLICITATION. The determination of a need for chiropractic care and the choice of a chiropractor are extremely important decisions and should not be based solely upon advertisements, solicitations or self-proclaimed expertise. This notice is required by the Missouri State Board of Chiropractic Examiners.

1. 5. A licensee may initiate personal con-

tact, including telephone contact, with a person for the purpose of offering to provide chiropractic care subject to the provisions of subsection (6)(D) herein. Any such personal contact, including telephone contact, which is made on behalf of a licensee by any third party or parties, shall be deemed to be contact made directly by the licensee for purposes of compliance with these rules.

1. (B) Every advertisement or solicitation shall include the following:

   1. 1. The name of at least one (1) licensee

responsible for its content and any potential violation of section 331.060, RSMo; and

1. 2. The term “chiropractor,” “doctor of

chiropractic,” “chiropractic physician,” or “D.C.”

1. (C) Advertisements and solicitations may contain:

   1. 1. The educational background of the

licensee;

1. 2. The basis on which fees are deter-

mined, including charges for specific services, so long as fees advertised remain effective for a reasonable time;

1. 3. Available credit; and
2. 4. Any other information that is not

false, misleading or deceptive.

1. (D) A licensee shall not initiate an individual written communication under paragraph (6)(A)3. or personal contact, including telephone contact under paragraph (6)(A)5., if the licensee knows or reasonably should know that the physical, emotional, or mental state of the person makes it unlikely that the person would exercise reasonable judgment in employing the services of a chiropractor. A written communication sent and received or a personal contact directed to any person known to have been involved in an accident, if made within thirty (30) days after such accident, is presumed to be written at a time or made at a time when the writer knows or reasonably should know that the physical, emotional, or mental state of the person makes it unlikely that the person would exercise reasonable judgment in employing a chiropractor, unless such written communication or personal contact, including telephone contact, is directed to a close friend, relative or former patient.

2. (E) An advertisement or solicitation, as defined in this rule, shall not be false, misleading or deceptive to the general public or persons to whom the advertisement or solicitation is primarily directed. False, misleading and/or deceptive shall include, but not be limited to, the following contents or omissions:

   1. 1. Any untrue statement;
   2. 2. Any matter, or presentation or

arrangement of any matter, in a manner or format which is false, misleading or deceptive to the public;

1. 3. Omission of any fact which under the

circumstances makes the statement false, misleading or deceptive to the public;

1. 4. Transmission in a manner which

involves coercion, intimidation, threats or harassing conduct;

1. 5. An attempt to attract patronage in a

manner which castigates, impugns, disparages, discredits or attacks other healing arts and sciences or other chiropractic physicians;

1. 6. Any self-laudatory statements; or
2. 7. Transmission to a person who has

made known to the licensee a desire not to receive communication from the licensee.

1. (F) The board presumes the following forms of advertising and/or solicitation to be false, misleading and/or deceptive and in violation of subsection (6)(E) of this rule:

   1. 1. An advertisement or solicitation

which contains guarantees or warranties regarding the result of a licensee’s services;

1. 2. An advertisement or solicitation

which contains testimonials about or endorsements of a licensee, unless—

1. A. The advertisement or solicitation

complies with subsection (6)(E) of this rule; and

1. B. The testimonial or endorsement is

made by the person who actually received the services or who has personal knowledge as to the facts stated, excepting however, testimonials and endorsements may be made by paid actors so long as the advertisement or solicitation contains a notice stating that paid actors have been used;

1. 3. An advertisement or solicitation

which is transmitted at the scene of an accident or en route to a hospital, emergency care center or other health care facility;

1. 4. Any advertisement or solicitation

using the phrase “no out-of-pocket expense,” “we accept what your insurance will pay” or any similar statement prior to the retention of services that a payment made by an insurance carrier or other third party payor with copayment or deductible features will be accepted by the licensee as payment in full, unless the advertisement shall also contain the following notice:

“This offer is only valid after the applicable insurance carrier or third party payor has been notified of the terms of the offer.”

The licensee will provide written notice disclosing the terms of such offer, agreement or waiver on any billing and/or third party claim.

1. (G) For the purpose of this rule, all required notices shall be at least ten (10) points in height if the advertisement or solicitation is written or printed and at least eighteen (18) point font if the advertisement or solicitation is made by means of television. Notices may be oral, if the form of advertisement or solicitation will not allow it to be in printed form.
2. (H) A licensee shall retain for two (2) years a true and correct copy or recording of any advertisement or solicitation made by written or electronic media along with a record of when and where it was used. Upon written request, the licensee shall make the copy or recording available to the board and, if requested, shall provide to the board evidence to support any factual or objective claim contained in the advertisement or solicitation.

1. (7) A chiropractic office shall not be closed until the board has been provided with information which in the board’s view is sufficient to assure the board that adequate measures have been taken by the licensee or licensee’s heirs to provide for the transfer of patient records, including X-rays, to either the patient or another health care provider of the patient’s choosing or to assure the board that the patient does not desire the records delivered to him/her or another health care provider.
2. (8) The licensee shall retain patient records for at least seven (7) years.
3. (9) Failure of the licensee to comply with section 191.227, RSMo shall be considered unprofessional conduct.

4. (10) Minimal record keeping standards apply to all licensed chiropractic physicians, chiropractic assistants and certified chiropractic technicians. These standards also apply to those examinations advertised at a reduced fee or free (no charge) service.

   1. (A) Adequate patient records shall be legibly maintained. Initial and follow-up services (daily records) shall consist of documentation to justify care. If abbreviations or symbols are used in the daily record keeping, a key must be provided.
   2. (B) Minimum record keeping regarding a patient shall include patient history, symptomatology, examination, diagnosis, prognosis and treatment.
   3. (C) Provided the board takes disciplinary action against a chiropractic physician for any reason, these minimal clinical standards will apply. It is understood that these procedures are the accepted standard(s) and anything less than this shall be considered unprofessional conduct in the practice of chiropractic.

5. (11) A nutritional evaluation which is in response to stimulation of the olfactory nerve receptors and those procedures including holding vitamins, minerals, herbs or any food or food product in the hand, laying vitamins, minerals, herbs or any food or food product on or near the skin and touching various areas of the skin, are unproven, could lead to errors in diagnosis and are potentially detrimental to the health of the patient being evaluated and is considered unprofessional conduct in the practice of chiropractic.

   1. (A) Nutritional evaluation shall include history; type of dysfunction; laboratory tests, if necessary; physical diagnosis; and dietary inadequacies. Nutritional evaluation without these procedures is deemed unprofessional conduct.
   2. (B) Nutritional evaluation which is in response to stimulation of the gustatory nerve receptors is not a diagnostic procedure but may be used as an adjunctive procedure when used in conjunction with subsection (10)(A).
6. (12) Any licensee who performs a chiropractic review under section 376.423, RSMo without having obtained a certification from the board or is not in compliance with 4 CSR 70-4 of the board’s rules shall be deemed to have engaged in unprofessional conduct in the practice of chiropractic.
7. (13) Violation of the Health Care Payment Fraud and Abuse Act, Missouri Revised Statutes section 191.900 et seq. or the “antikickback” portions of the Medicare/Medicaid anti-fraud and abuse statute, 42 United States Code section 1320a-7b[b], by knowingly and willingly offering, paying, soliciting or receiving remuneration in order to induce business reimbursed under the Medicare or state administered health care programs will be considered unprofessional or improper conduct in the practice of chiropractic. Conduct will not be considered a violation of this rule, if the ownership or investment interest in such service meets the requirements of the “safe harbor” provisions of Title 42 Code of Federal Regulations part 1001.

AUTHORITY: sections 331.060 and 331.100.2, RSMo 2000.* This rule originally filed as 4 CSR 70-2.060. This version of rule filed Dec. 17, 1975, effective Dec. 27, 1975. Amended: Filed April 6, 1978, effective Aug. 11, 1978. Amended: Filed July 5, 1978, effective Oct. 13, 1978. Rescinded and readopted: Filed Dec. 9, 1981, effective April 11, 1982. Rescinded and readopted: Filed July 9, 1982, effective Nov. 11, 1982. Amended: Filed Sept. 12, 1983, effective Jan. 13, 1984. Amended: Filed June 11, 1985, effective Oct. 26, 1985. Rescinded and readopted: Filed April 18, 1989, effective July 13, 1989. Amended: Filed April 18, 1990, effective June 30, 1990. Amended: Filed Aug. 14, 1990, effective Dec. 31, 1990. Amended: Filed March 4, 1991, effective July 8, 1991. 20 CSR 2070-2 Amended: Filed Sept. 17, 1991, effective Feb. 6, 1992. Amended: Filed Dec. 3, 1991, effective April 9, 1992. Amended: Filed Jan. 23, 1992, effective June 25, 1992. Amended: Filed Feb. 4, 1992, effective June 25, 1992. Amended: Filed May 13, 1992, effective Jan. 15, 1993. Amended: Filed June 15, 1992, effective Jan. 15, 1993. Amended: Filed July 22, 1993, effective Jan. 31, 1994. Amended: Filed Dec. 21, 1995, effective June 30, 1996. Amended: Filed Nov. 6, 1996, effective May 30, 1997. Amended: Filed April 29, 1998, effective Nov. 30, 1998. Amended: Filed July 31, 2003, effective Jan. 30, 2004. Amended: Filed April 1, 2005, effective Oct. 30, 2005. Moved to 20 CSR 2070-2.060, effective Aug. 28, 2006.

*Original authority: 331.060, RSMo 1939, amended 1969, 1971, 1972, 1981, 1987; and 331.100.2, RSMo 1939, amended 1949, 1969, 1980, 1981.