NEW JERSEY REGISTER
VOLUME 33, NUMBER 9
MONDAY, ,MAY 7, 2001
RULE PROPOSAL

LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
STATE BOARD OF CHIROPRACTIC EXAMINERS
STATE BOARD OF CHIROPRACTIC EXAMINERS RULES

Additions are indicated by <<+ Text +>>; deletions by <<- Text ->>.
Changes in tables are made but not highlighted.

Proposed Readoption with Amendments: N.J.A.C. 13:44E

Authorized By: State Board of Chiropractic Examiners, Kevin Earle, Executive Director.

Authority: N.J.S.A. 45:1-3.2, 45:9-14.5 and 41.23.
Proposal Number: PRN 2001-152.

Submit comments by June 6, 2001 to:

Kevin B. Earle

Executive Director

State Board of Chiropractic Examiners

PO Box 45004

Newark, NJ 07101

The agency proposal follows:

Summary

Pursuant to the provisions of Executive Order No. 66(1978), the rules at N.J.A.C. 13:44E will expire on June 28, 2001. As required by the Executive Order, the Board of Chiropractic Examiners ("the Board") has reviewed these rules and determined them to be necessary, reasonable and proper for the purpose for which they were originally promulgated.

A summary of each section and the proposed amendments follows:

Subchapter 1 concerns with the scope of practice.

N.J.A.C. 13:44E-1.1 sets forth the scope of chiropractic practice. The rule defines the practice of chiropractic, states that a chiropractic diagnosis or analysis shall be based upon a chiropractic examination appropriate to the presenting patient, details which diagnostic and analytical procedures are within the scope of practice and states that a licensee may offer general nutritional advice to a patient when the advice is incidental to the chiropractic care being provided. The Board proposes amendments to this rule, and throughout the rules, to change the term "chiropractic treatment" to "chiropractic care." Technical amendments are proposed to the rule.

The Board proposes a new subchapter 1A which sets forth requirements for licensure as a chiropractor in New Jersey.

Proposed new rule N.J.A.C. 13:44E-1A.1 sets forth the educational requirements that an applicant must meet to be eligible for initial licensure as a chiropractor. The rule states that an applicant must be at least 18 years of age, be of good moral character, have successfully completed high school or its equivalent, completed two years of study in an accredited college or university, graduated from a chiropractic college or university, passed the National Board of Chiropractic Examiners Examination and passed the New Jersey Chiropractic Jurisprudence Examination.

Proposed new rule N.J.A.C. 13:44E-1A.2 contains the information that an applicant for licensure must submit to the Board which includes the completed application, official transcripts, proof of the completion of the chiropractic examination and the application fee.

Proposed new rule N.J.A.C. 13:44E-1A.3 states that an applicant licensed to practice in another state will be granted a license to practice in New Jersey without further examination if the licensure and examination standards of the licensing board in the other state are equivalent to those in this subchapter and the Board receives evidence that the applicant is in good standing in the jurisdiction in which they practice. The applicant must furnish a transcript demonstrating that he or she has completed the requisite educational requirements and pay the endorsement fee. The proposed new rule requires that the applicant must also take the New Jersey Jurisprudence Examination and provides an alternate examination for an applicant who does not satisfy the prerequisite educational requirements.

Proposed new rule N.J.A.C. 13:44E-1A.4 states that licenses to practice chiropractic are issued for a two year period and renewed biennially. The proposed new rule requires a licensed chiropractor to submit a renewal application and pay a renewal fee and states that the licensed chiropractor may renew a license within 30 days of its expiration if he or she pays an additional late fee. A license that is not renewed within that 30 day period expires, and an individual who continues to practice with an expired license is deemed to be engaged in unlicensed practice.

Subchapter 2 contains the general rules of practice.

N.J.A.C. 13:44E-2.1 regulates the advertising practices of licensed chiropractors. This section defines advertising words and terms, permits licensees to advertise in the print or electronic media, specifies acts which may be deemed professional misconduct, requires licensed chiropractors to substantiate any claims made in advertisements, prohibits uninvited in-person solicitation, sets forth how fees and discounts may be advertised, outlines what information must be included in each advertisement and details various recordkeeping requirements. Minor technical amendments for clarity are proposed to the rule.

N.J.A.C. 13:44E-2.2 requires licensed chiropractors to maintain patient records. The rule outlines how the patient records are to be maintained and labeled, and sets forth requirements for patient access, confidentiality, and third party examination of the records. A proposed amendment adds a provision which requires the records of a minor child to be kept for seven years from the date of the last entry or from the date of majority, whichever is later.

N.J.A.C. 13:44E-2.3 prohibits sexual harassment of or sexual contact with a patient by a licensed chiropractor.

N.J.A.C. 13:44E-2.4 requires that each patient treated in a chiropractic facility have a chiropractor of record. The rule details how the chiropractor of record and others who render services are to be identified in the patient record. The rule also sets forth fee reimbursement requirements. Technical amendments are proposed to the rule.

N.J.A.C. 13:44E-2.5 sets forth the fee schedule. The proposed amendment deletes the examination fee because the Board no longer gives an examination.

The reservation of N.J.A.C. 13:44E-2.6 is deleted.

N.J.A.C. 13:44E-2.6, recodified from 2.7, states that it is professional misconduct for licensed chiropractors to profit from the referral of a patient. The prohibition, however, does not include the division of fees among licensees in a bona fide relationship to deliver professional services.

N.J.A.C. 13:44E-2.7, recodified from 2.8, sets forth the tasks that may, and may not, be delegable to unlicensed assistants and the procedures the licensee must follow in those instances of delegation.

N.J.A.C. 13:44E-2.8, recodified from 2.9, requires licensed chiropractors to notify the Board of a change of address, and that the address on file with the Board shall be used for the service of process.

N.J.A.C. 13:44E-2.9, recodified from 2.10, requires licensed chiropractors to display their licenses in the licensees' principal offices and duplicates must be displayed in all facilities where the licensed chiropractors practice.

N.J.A.C. 13:44E-2.10, recodified from 2.11, provides that a licensee has a right to a hearing prior to a suspension, revocation or the refusal by the Board to renew a license.

The reservation of N.J.A.C. 13:44E-2.12 is deleted.

N.J.A.C. 13:44E-2.11, recodified from 2.13, prohibits overutilization of services and excessive fees. The rule also describes the factors which may be considered in determining whether the fee is excessive. Minor technical amendments are proposed.

N.J.A.C. 13:44E-2.12, recodified from 2.14, addresses referrals of patients to physical therapists and the information which must be contained in the referrals. The rule states that once the physical therapist has completed the physical therapy examination, the referring chiropractor must consult with the physical therapist, and describes the manner in which that consultation must take place. Technical amendments are proposed to the rule.

N.J.A.C. 13:44E-2.13, recodified from 2.15, sets forth the examination requirements for licensure as a chiropractor. The proposed amendment deletes subsection (a), which expired on December 31, 2000, pursuant to subsection (e), also deleted.

Subchapter 3 contains provisions which address how determinations concerning the validity of diagnostic tests and other special examinations are to be made.

N.J.A.C. 13:44E-3.1 defines words and terms used in the subchapter. A technical amendment to the term chiropractic physician is proposed.

N.J.A.C. 13:44E-3.2 authorizes trained chiropractic physicians to perform and charge for diagnostic tests performed in conformance with the rules. The rule lists certain tests which are not recognized as scientifically supportable and may not be billed to the patient or the third party payor. Additionally, the rule lists a number of other tests which, if clinically supported, are deemed to be valid for the evaluation of some conditions and, in some instances, subject to specific limitations on timing or frequency. The rule also makes clear that any test recognized as failing to yield sufficiently valuable data, or undertaken in circumstances where its validity is not recognized, may be performed; but only with the informed consent of the patient. These tests may not be billed to the patient.

N.J.A.C. 13:44E-3.3 identifies tests which are not to be performed by chiropractic physicians, but rather must be referred to an appropriately trained medical doctor.

N.J.A.C. 13:44E-3.4 establishes basic responsibilities that must be met by both chiropractic physicians who perform electrodiagnostic testing and special examination, and those who request such tests. The rule delineates specific pre-test responsibilities to be conducted by chiropractic physicians who intend to perform these specialized tests. The rule also states what tests the chiropractic physician may perform, and when a patient may be referred for specialized testing if the prerequisites are met.

N.J.A.C. 13:44E-3.5 establishes educational requirements for those seeking to perform electrodiagnostic tests and special examinations.

N.J.A.C. 13:44E-3.6 requires both treating and testing chiropractic physicians to provide written information to the patient regarding risks of the procedure and establishes standards for special testing equipment.

N.J.A.C. 13:44E-3.7 prohibits use by a chiropractic physician of an unlicensed assistant unless the testing chiropractic physician is present in the room, makes all professional decisions, directly supervises the testing, and is not concurrently involved in testing or supervision of another patient.

N.J.A.C. 13:44E-3.8 establishes requirements for the preparation of a proper professional report of electrodiagnostic tests and special examinations. The expected content of these reports is outlined in detail. The rule also establishes the requirements for the maintenance of the underlying data.

N.J.A.C. 13:44E-3.9 mandates that all referrals are to be in accord with applicable law and that appropriate disclosure to the patient of any significant beneficial interest is required.

N.J.A.C. 13:44E-3.10 requires that before any diagnostic test is performed, the patient must be informed of the anticipated fee in a timely manner sufficient to allow the physician, and or patient, to ascertain the financial responsibility for the procedure. Additionally, the fee must not violate proposed N.J.A.C. 13:44E-2.11, which prohibits excessive fees.

N.J.A.C. 13:44E-3.11 directs that all prohibitions or limitations on permissible performance of tests or billing must be prospective with regard to rule compliance, but does not limit the Board's authority to take disciplinary action.

Social Impact

The proposed readoption of N.J.A.C. 13:44E and the proposed amendments will benefit both the public and licensees. An analysis of the social impact of each subchapter follows:

Subchapter 1 will have a beneficial impact on licensees by setting forth the scope of practice and, in particular, by providing specific examples of diagnostic procedures which may be undertaken.

The proposed new rules in subchapter 1A will benefit the public and licensees. Licensees will benefit from setting forth the licensing requirements, application procedures and biennial renewal period. The public will benefit from the knowledge that all licensees meet all requirements for licensure.

Subchapter 2 benefits licensed chiropractors and the public by setting forth general rules of chiropractic practice. The rule on advertising practices, N.J.A.C. 13:44E-2.1, has a beneficial impact on the public by improving the quality of information available about a practicing chiropractor's services and expertise in order to help the consumer make an informed choice from among those persons offering chiropractic services. The public also benefits from the protection against overaggressive and/or deceptive solicitation of potential patients. The public benefits from the rule preventing dishonest chiropractors from attempting to circumvent advertisements for free services by falsely suggesting an immediate need for additional services, unless a waiver is signed by the patient. This provision also benefits licensees by preserving the integrity of the profession.

Patients benefit from several aspects of the patient record rule, N.J.A.C. 13:44E-2.2. The rule assures that licensees maintain a clear and complete patient record in case the patient needs to be evaluated by another health professional or evaluator. The provisions regarding timely release of records to the patient or another designated health care provider should ensure that the patient has ready access to his or her records, which is particularly important where the patient's continued care is contingent upon receipt of the records. Patients also benefit from the prohibition against a licensee's refusal to provide records if the records are needed by another health care professional for the purpose of rendering care on the grounds that the patient owes the licensee an unpaid balance. Patients are also protected against unwarranted disclosure of the contents of their records. The proposed amendments will benefit patients who are minors by requiring that their records be retained for seven years from the date of the last entry, or seven years from the date of majority, whichever is later.

Mandating the compliance of licensed chiropractors with the sexual misconduct prohibitions in N.J.A.C. 13:44E-2.3 will have a positive impact upon the public by increasing confidence in the chiropractic profession and enhancing the quality of chiropractic services, and by setting forth the parameters of appropriate conduct. The rule also provides needed protection to patients, employees and co-workers of licensed chiropractors from sexual harassment and sexual contact. Patients will be able to receive chiropractic services without fear of unwanted sexual contact or harassment. Employees and co-workers will be afforded workplace protection against unwanted advances and harassment, creating a safer and more productive workplace environment.

The rule regarding the chiropractor of record and fee reimbursement, N.J.A.C. 13:44E-2.4, will benefit the public. By designating a single chiropractor of record, other persons reviewing the records will be able to identify the professional who rendered specific treatment. This benefits the patient seeking to understand or make use of his or her records; and permits a subsequent treating chiropractor to be fully apprized of the care previously rendered.

The rule regarding delegable tasks and functions of unlicensed assistants, proposed N.J.A.C. 13:44E-2.7, will benefit licensees by offering a list of duties that may be delegated to assistants. Patients will benefit from the safeguards contained in the rule.

The rule requiring a licensee to notify the Board of any change of address, proposed N.J.A.C. 13:44E-2.8, will enhance the Board's ability to contact its licensees. Licensees and the public will also benefit in that the information they receive from the Board with regard to a licensee's location will be accurate and quickly accessible.

The rule concerning the display of the license, proposed N.J.A.C. 13:44E- 2.9, has a positive impact by providing patients with evidence of licensure status and by removing the burden of patients having to make an independent inquiry to obtain this information.

The rule concerning the right to a hearing, proposed N.J.A.C. 13:44E-2.10, benefits licensees by informing them of their right to request a hearing prior to suspension, revocation or refusal by the Board to renew their licenses.

The rule concerning overutilization of chiropractic services and excessive fees, proposed N.J.A.C. 13:44E-2.11, will benefit the public by reducing unnecessary chiropractic treatments and deterring the charging of excessive fees for chiropractic services.

The rule concerning the referral of patients to physical therapists, proposed N.J.A.C. 13:44E-2.12, will have a positive impact on the public and licensees. Patients will benefit because the rule contains a mechanism by which referring chiropractors and physical therapists must consult with one another to resolve whatever questions arise as to the proper programs of treatment. Their interaction will result in post-examination discussions that promise to improve the coordination of the patient's plan of care, and that will result in greater fine-tuning of chiropractic and physical therapy treatment. Chiropractic licensees will also benefit from this rule because the purpose of the referral and the spinal component of the patient's problem will be documented along with their treatment directions.

The rule concerning the chiropractic licensure examination, proposed N.J.A.C. 13:44E-2.13, will benefit the public by requiring that candidates for licensure have the skills required to pass the four sections of the National Board of Chiropractic Examiners Examination and knowledge necessary to pass the jurisprudence examination administered by the Board. Acceptance of Parts I, II, III and IV of the National Board of Chiropractic Examiners Examination will offer candidates an objective and psychometrically sound examination.

The rules proposed for readoption in subchapter 3 will have significant impact upon chiropractic licensees and their patients. The rules are designed to reduce the incidence of costly, and unnecessary examinations. Those tests requested or performed in compliance with these rules will be supported by documented patient examinations professional and scientific rationales; and will be selected for their ability to directly enhance the chiropractic management of the seriously injured patient. The general public will benefit because the rules are intended to reduce or eliminate costs associated with inappropriate medical treatment and tests while serving to promote efficient and quality medical care.

Economic Impact

The rules proposed for readoption and the proposed new rules will have an economic impact on licensed chiropractors in New Jersey.

Proposed new subchapter 1A will have an economic impact on applicants for chiropractic licensure and licensees. Applicants will incur costs in completing the educational and examination requirements and paying the application fee. Licensees will incur a biennial license renewal fee and may incur a late fee if they fail to renew their license within 30 days of its expiration.

Subchapter 2 will have various economic impacts on licensees. The advertising rule, N.J.A.C. 13:44E-2.1, has a favorable impact upon consumers by allowing consumers to anticipate actual as well as potential additional costs of the services offered. Additionally, consumers are able to make meaningful and accurate comparisons based upon standardized requirements for disclosing a fixed or stated range of fees against which an offer of discounted service is to be made, or value of a free service to be measured. Patients also benefit from deterrence of bait-and-switch tactics arising from a supposed immediate need for chiropractic services, because the waiver-form mechanism discloses to consumers that additional services may not ordinarily be charges for when taking advantage of advertised free or discounted services.

The recordkeeping tasks in the patient record rule, N.J.A.C. 13:44E-2.2, should require only a small portion of the chiropractor's time; therefore, the expense should be minimal. The only expense that a consumer might incur is the cost for photocopying the patient record.

The sexual misconduct rule, N.J.A.C. 13:44E-2.3, may include administrative and postal costs involved for a licensee to terminate the patient-chiropractor relationship. These costs are expected to be minimal and are greatly outweighed by the need to protect the health and welfare of the public by prohibiting conduct which is considered inappropriate in the context of the professional relationship. The rule may have some economic impact upon licensees who fail to abide by the standards, and therefore, may be subject to penalties and loss of license.

Under N.J.A.C. 13:44E-2.4, the treating chiropractor and the owner of the facility will be impacted by being held jointly and severally responsible for the repayment of fees to patients when a licensee renders services in violation of N.J.S.A. 45:1-21.

The fee schedule in N.J.A.C. 13:44E-2.5 has a direct economic impact on licensees and, to the extent the proposed fees may be passed along to the patient as a cost of practice, has an indirect economic impact on consumers.

Licensees are impacted by the banning of referral fees under proposed N.J.A.C. 13:44E-2.6 but benefit from the provision allowing the division of fees among licensees engaged in bona fide employment, partnership or corporate relationship for the delivery of professional services.

Licensees will be impacted by having to pay the change of address notification fee and the duplicate license fee, under proposed N.J.A.C. 13:44E-2.9 and 2.10, respectively.

The rule prohibiting the overutilization of chiropractic services and the charging of excessive fees, proposed N.J.A.C. 13:44E-2.11, has a positive economic impact on the public. Overutilization inflates the cost of health care services and increases amounts paid by patients or reimbursed by third-party payors. By identifying those practices that may directly or indirectly increase costs to the consumer, the rule clearly protects the public.

The rule concerning the referral of patients by chiropractors to physical therapists, proposed N.J.A.C. 13:44E-2.12, positively impacts consumers by promoting efficiency and team work among referring chiropractors and physical therapists. To the extent that a program of treatment is rejected by the physical therapist, and is, therefore, not administered to the patient, the patient will not incur the expense for the unnecessary treatment. In addition, if a particular plan of treatment is failing or is less effective than desired, the ongoing communication between the referring chiropractor and physical therapist will allow the two professionals to improve or change the program of treatment in order to make it more effective for the patient, thus saving the patient from paying unnecessary fees.

The examination rule, proposed N.J.A.C. 13:44E-2.13, will have an economic impact upon applicants seeking a chiropractic license in that they must pay for the national and state examinations. The fee for the national examination, however, is set by the National Board of Chiropractic Examiners and is not under control of the Board.

Subchapter 3 has an economic impact on chiropractic physicians because the rules limit the ordering or performing of unnecessary tests, and offering or accepting improper payments for test referrals. Patients and third party payors benefit from these rules because the provisions are guided by principles of professional integrity. The rules have beneficial economic impact because of the heightened skills which chiropractic physicians will bring to bear upon the analysis of patient conditions and treatments, thus rendering more skillful treatment for conditions amenable to chiropractic care, and enhancing the speed for recovery from injury.

The chiropractic physicians who wish to perform electrodiagnostic tests and special examinations permitted by the rules will be required to submit to the Board a $50.00 fee to receive a certificate of competency to perform designated tests and examinations. This is a one time fee, however, and once a chiropractic physician has received Board authorization to perform the permitted tests and examinations, he or she may apply for authorization to perform other permitted tests and examinations for which the chiropractic physician was not previously authorized without the payment of an additional fee. Chiropractic physicians who elect to attain the certification of competency in electrodiagnostic testing incur fees and costs associated with obtaining necessary training, such as those associated with tuition, enrollment fees and course materials. These expenses vary depending upon the number of courses taken and the differences in fees charged by different schools.

Federal Standards Statement

A Federal standards analysis is not required because there are no Federal standards or requirements applicable to the rules proposed for readoption and the proposed amendments.

Jobs Impact

The Board does not believe that the rules proposed for readoption and the proposed amendments will either increase or decrease jobs in the State.

Agriculture Industry Impact

The rules proposed for readoption and the proposed amendments will have no impact on the agriculture industry.

Regulatory Flexibility Analysis

The Regulatory Flexibility Act, N.J.S.A. 52:14B-16 et seq. (the Act), requires the Board to give a description of the types and an estimate of the number of small businesses to which the proposed rules will apply. If, for the purposes of the Act, the approximately 3,200 chiropractors licensed by the Board are deemed "small businesses," then the following analysis applies.

The Act requires the Board to set forth the reporting, recordkeeping, and other compliance requirements of the proposed rules including the kinds of professional services likely to be needed to comply with the requirements. The Act further requires the Board to estimate the initial and annual compliance costs, outline the manner in which it has designed the rules to minimize any adverse economic impact upon small businesses, and to set forth whether the rules establish differing compliance requirements for small businesses.

The rules contain no reporting requirements; however, recordkeeping requirements are found throughout the rules as described in the Summary above. N.J.A.C. 13:44E-2.1 details the requirement for the retention of advertising records and N.J.A.C. 13:44E-2.2 outlines the requirements that a licensee must meet in keeping patient records. Subchapter 3 concerning diagnostic testing requires recordkeeping and detailed chart documentation of the clinical examination and decision making required to justify requesting or performing special examinations. A chiropractic physician who wishes to perform such special examinations is required to report his or her training and competency evaluations to the Board and to submit a one time fee for processing an application for registration as a practitioner authorized to practice these special examinations. The rules also require the documentation of the name of any unlicensed assistant used in such testing, and the documentation of, and the basis for, the fee.

The rules also impose numerous compliance requirements which have been further described in the Summary above.

N.J.A.C. 13:44E-1.1 identifies the scope of practice for licensees and how licensees must conduct initial consultations and chiropractic examinations.

Subchapter 2 imposes numerous compliance requirements on licensees such as advertising requirements, how licensees must keep patient records, what constitutes sexual misconduct by licensees, the requirements for identifying the chiropractor of record, paying fees according to an established schedule, prohibition of profiting from the referral of patients, setting forth tasks that licensees may delegate to unlicensed assistants, advising the Board of a change of address, displaying a license, prohibiting licensees from overutilizing services and charging excessive fees, procedures for the referral of patients, and licensure examination requirements.

Proposed new subchapter 1A imposes the following requirements for licensure; proposed new rule N.J.A.C. 13:44E-1A.1 outlines the eligibility and educational requirements for applicants for licensure; proposed new rule N.J.A.C. 13:44E-1A.2 sets forth what an applicant must submit to the Board in order to complete the application process; proposed new rule N.J.A.C. 13:44E-1A.3 sets forth what an applicant licensed in another jurisdiction must submit to the Board in order to be granted a license to practice chiropractic in New Jersey without further examination; proposed new rule N.J.A.C. 13:44E-1A.4 requires that a license must be renewed biennially. Additionally, N.J.A.C. 13:44E-1A.4 states that a late fee must be paid if the license is not renewed within 30 days of expiration.

Costs of compliance are discussed in the Economic Impact above. The Board believes that no professional services are likely to be needed to comply with the rules proposed for readoption or the amendments. The Board considers the proposed readoption with amendments necessary to preserve the health, safety and welfare of chiropractic patients. Compliance requirements do not differ based on size of the business in order to ensure that all chiropractic services are provided uniformly throughout the State.

Full text of the proposed readoption may be found in the New Jersey Administrative Code at N.J.A.C. 13:44E.

Full text of the proposed amendments follows:

SUBCHAPTER 1. PURPOSE AND SCOPE; DEFINITIONS

<< NJ ADC 13:44E-1.1 >>

13:44E-1.1 Scope of practice

(a) The practice of chiropractic is that patient health care discipline whose methodology is the adjustment and/or manipulation of the articulations of the spine and related structures. During the initial consultation and before commencing chiropractic care, a licensee shall identify <<+and document+>> a clinical condition warranting chiropractic <<-treatment->> <<+ care+>>. Nothing herein contained shall be deemed to prohibit a licensee from caring for chiropractic subluxation as determined by chiropractic analytical procedures. Chiropractic analysis which identifies the existence of a subluxation may be the basis for chiropractic care even in the absence of a subjective complaint or other objective findings.

(b) A chiropractic diagnosis or analysis shall be based upon a chiropractic examination appropriate to the presenting patient. Should the <<- evaluation->> <<+examination+>> indicate abnormality not generally recognized as amendable to chiropractic <<-treatment->> <<+care+>>, a licensee shall refer the patient to an appropriate health care provider. Nothing herein contained shall preclude a licensee from rendering concurrent and/or supportive chiropractic care to any patient so referred.

(c) The following diagnostic and analytical procedures are within the scope of practice of a licensee:

1.-2. (No change.)

3. The ordering or performing of reagent strip tests (dipstick urinalysis) <<+consistent with chiropractic practice+>>;

4. The ordering, but not performing, of such other diagnostic or analytical tests consistent with chiropractic practice including, but not limited to, computerized axial tomography (CT), magnetic resonance imaging (MRI), bone scan <<-and->><<+,+>> invasive electromyography (EMG) <<+and chest x-ray+>>;

5. The requesting or performing of such other diagnostic or analytical tests consistent with chiropractic practice including, but not limited to, non- invasive muscle testing and tests using neurocalometer-type devices; <<- and->>

6. The requesting or performing of electrodiagnostic tests or other special examinations, to the extent and in the manner authorized by N.J.A.C. 13:44E-3<<-.->><<+; and+>>

<<+7. In conjunction with a chiropractic adjustment, the ordering and/or administering of physical modalities where clinically indicated.+>>

(d) (No change.)

<<-(e) A licensee may order and/or administer physical modalities, where indicated, in conjunction with a spinal adjustment.->>

<<+SUBCHAPTER 1A. LICENSURE+>>

<< NJ ADC 13:44E-1A.1 >>

<<+13:44E-1A.1 Licensing requirements for a chiropractor+>>

<<+(a) To be eligible for licensure as a chiropractor in New Jersey, an applicant shall:+>>

<<+1. Be at least 18 years of age;+>>

<<+2. Be of good moral character as demonstrated on the application;+>>

<<+3. Have successfully completed high school or its equivalent;+>>:

<<+4. Have successfully:+>>

<<+i. Completed two years of study in an accredited college or university with at least one and one-half of the two years of study prior to commencing study in a chiropractic college or university within a course of study which meets the requirements set forth in N.J.S.A. 45:9-41.5; and+>>

<<+ii. Graduated from a chiropractic college or university, which meets the requirements set forth in N.J.S.A. 45:9-41.5 during the applicant's entire course of study;+>>

<<+5. Have passed the National Board of Chiropractic Examiners Examination pursuant to N.J.A.C. 13:44E-2.13; and+>>

<<+6. Have passed the New Jersey Chiropractic Jurisprudence Examination.+>>

<< NJ ADC 13:44E-1A.2 >>

<<+13:44E-1A.2 Application for license: chiropractor+>>

<<+(a) An applicant for licensure as a chiropractor in New Jersey shall submit the following to the Board:+>>

<<+1. A completed application form provided by the Board which shall contain the applicant's name, address, social security number, academic qualifications, licensure information from other states, resume, questions demonstrating moral character, confidential questions concerning the applicant's fitness to practice and child support questions;+>>

<<+2. Official transcripts demonstrating completion of the educational requirements pursuant to N.J.A.C. 13:44E-1A.1(a)4;+>>

<<+3. Proof of successful completion of the National Board of Chiropractic Examiners Examination pursuant to N.J.A.C. 13:44E-2.13; and+>>

<<+4. The application fee set forth in N.J.A.C. 13:44E-2.5.+>>

<< NJ ADC 13:44E-1A.3 >>

<<+13:44E-1A.3 Applicants licensed in other states+>>

<<+(a) An applicant who is licensed to practice chiropractic by an examining and licensing board of another state shall be granted a license to practice chiropractic in New Jersey without further examination provided that:+>>

<<+1. The examining and licensing board of the applicant's state of licensure has licensure and examination requirements equivalent to those of this State;+>>

<<+2. The applicant furnishes an official transcript demonstrating that he or she has completed the educational requirements set forth in N.J.A.C. 13:44E-1A.1(a)4;+>>

<<+3. The Board has received evidence of the applicant's good standing in any jurisdiction where he or she is or has been licensed; and+>>

<<+4. The applicant pays the endorsement license fee as set forth in N.J.A.C. 13:44E-2.5.+>>

<<+(b) An applicant for a licensure to practice chiropractic in this State who holds a valid license to practice chiropractic in another state shall be required to successfully complete the New Jersey Jurisprudence Examination.+>>

<<+(c) An applicant who holds a license in good standing to practice chiropractic in another state, who has five years of postgraduate chiropractic clinical experience and who does not satisfy the prerequisite educational requirements of N.J.A.C. 13:44E-1A.1(a)4i, shall be granted a license to practice chiropractic in New Jersey provided that the applicant has passed the National Board of Chiropractic Examiners Special Purposes Examination for Chiropractic.+>>

<< NJ ADC 13:44E-1A.4 >>

<<+13:44E-1A.4 Biennial license renewal+>>

<<+(a) Licenses to practice chiropractic shall be issued for a period of two years and be renewed biennially. A licensee who seeks renewal of his or her license shall submit a license renewal application and the license renewal fee set forth in N.J.A.C. 13:44E-2.5 to the Board prior to the expiration of the current license.+>>

<<+(b) If a licensee does not renew his or her license prior to its expiration date, the licensee may renew the license within 30 days of its expiration by submitting a renewal application, a license renewal fee and a late fee, as set forth in N.J.A.C. 13:44E-2.5.+>>

<<+(c) A license that is not renewed within 30 days of its expiration date shall expire. Any individual who continues to practice with an expired license after 30 days following the license expiration date shall be deemed to be engaged in unlicensed practice.+>>

<<+(d) Falsification of any information submitted with the renewal application may result in penalties and/or suspension of the license pursuant to N.J.S.A. 45:1-21 through 25.+>>

SUBCHAPTER 2. GENERAL RULES OF PRACTICE

<< NJ ADC 13:44E-2.1 >>

13:44E-2.1 Advertising

(a) The following words and terms, when used in this section, shall have the following meanings unless the context clearly indicates otherwise.

1. <<-The term "advertisement" shall refer to->> <<+"Advertisement" means+>> the attempt, directly or indirectly by publication, dissemination, solicitation, endorsement or circulation in print or electronic media or in any other way, to attract directly or indirectly any person to enter into an expressed or implied agreement to accept chiropractic services or <<- treatment->> <<+care+>> or goods related thereto.

2. <<-The term "electronic media" shall include,->> <<+"Electronic media" means,+>> but <<+is+>> not <<-be->> limited to, radio, television, telephone, facsimile machine, and computer.

3. <<-The term "print media" shall refer to->> <<+"Print media" means+>>: newspapers, magazines, periodicals, professional journals, telephone directories, circulars, handbills, fliers or other publications, the content of which is disseminated by means of the printed word.

4. <<-The term "range of fees" shall refer to->> <<+"Range of fees" means+>> an expressly stated upper and lower limit on the fee charged for a professional service.

5. <<-The term "routine professional service" shall refer to->> <<+ "Routine professional service" means+>> a service which the advertising licensee, professional association or institution providing chiropractic care routinely performs.

(b)-(e) (No change.)

(f) Advertising making reference to or setting forth a fee shall be limited to that which contains a fixed or a stated range of fees for a specifically described professional service or class of services. A licensee who advertises shall disclose all the relevant variables and considerations which are ordinarily included in such a service so that the fees will not be misunderstood. In the absence of such a disclosure, the stated fees shall be presumed to include everything ordinarily required for such a service. No additional charges shall be made for an advertised service unless the advertisement includes the following disclaimer:

"Additional charges may be incurred for related services which may be required in individual cases."

<<+1.+>> The disclaimer <<-cannot->> <<+as set forth above shall not+>> be used for treatment where related services are ordinarily required.

<<-1.->><<+2.+>> In any advertisement in which examination fees are set forth, the cost of x-rays shall also be set forth along with the disclosure: "if needed."

(g) Offers of discounts or fee reductions or free services shall indicate the advertiser's fixed or stated range of fees against which said discount is to be made and/or the value of the free services. Chiropractic services which are routinely or ordinarily performed free of charge, shall be clearly and conspicuously stated in the body of the advertisement as such.

1.-3. (No change.)

4. In the event a patient responding to an advertisement offering free or reduced fee services is in need of services other than those advertised as free or reduced, including extraordinary diagnostic services or <<-emergency treatment services->> <<+immediate chiropractic care+>>, the <<- license->> <<+licensee+>> shall not charge for any such services rendered during a period of 24 hours from the time the advertised free service was rendered unless the practitioner obtains a signed waiver from the patient. The waiver shall be in the following form:

WAIVER

I have responded to an advertisement for a free examination or initial consultation with Dr. _______ D.C. Dr. _______ has explained to me that, pursuant to the regulations of the New Jersey Board of Chiropractic Examiners, he or she cannot charge for any service rendered during a period of 24 hours from the time he or she gives me the free examination or consultation examination or consultation unless there is an <<-emergency->> <<+ immediate+>> need for services and I sign this waiver.

I have what I believe is a need for <<-emergency treatment->> <<+ immediate chiropractic care+>>. Therefore, I agree to sign this waiver and to pay for the <<-emergency treatment->> <<+immediate chiropractic care+>> rendered within the 24-hour period. The amount Dr. _______ will charge me for <<-treatment->> <<+chiropractic care+>> is $_______.00. This figure was written on the line before I signed this waiver.

I have been given a copy of this waiver by Dr. _______ or someone from his or her office. If I have any concerns, I can write to the New Jersey State Board of Chiropractic Examiners at PO Box 45004, Newark, NJ 07101.

Patient's signature ___________________________________________________________

Patient's name printed ________________________________________________________

Date __________________________________________________________________________

(h)-(k) (No change.)

(l) A licensee shall <<-be required to keep->> <<+retain+>> a copy of all advertisements for a period of three years. All advertisements in the licensee's possession shall indicate the accurate date and place of publication <<+and/or dissemination+>>.

<< NJ ADC 13:44E-2.2 >>

13:44E-2.2 Patient records

(a) A contemporaneous, permanent patient record shall be prepared and maintained by a licensee for each person seeking chiropractic services, regardless of whether any <<-treatment->> <<+care+>> is actually rendered or whether any fee is charged. Licensees also shall maintain records relating to billings made to patients and third party carriersfor professional services. All <<-treatment->> <<+patient+>> records, bills and claim forms shall accurately reflect the <<-treatment->> <<+care+>> or services rendered. Such records shall include, as a minimum:

1.-5. (No change.)

6. A <<-treatment->> <<+care+>> plan;

7. Any orders for tests or consultations <<+including the clinical indications+>> and the results thereof;

8. (No change.)

9. A description of <<-treatment->> <<+care+>> or services rendered at each visit together with the name of the licensee or other person rendering the <<-treatment->> <<+care+>>;

10. Notation of significant changes in patient's condition and/or significant changes in <<-treatment->> <<+care+>> plan;

11.-12. (No change.)

(b) Patient records, including all radiographs and other diagnostic findings, shall be maintained for at least seven years from the date of the last entry. <<+In the case of a minor child, records shall be kept for seven years from the date of the last entry or seven years from the date of majority, whichever is later.+>>

(c) (No change.)

(d) Licensees shall provide access to patient records to the patient or the patient's authorized representative in accordance with the following:

1. (No change.)

2. Except where the complete record is required by applicable law, the licensee may elect to provide a summary of the record, as long as that summary <<-adequately->> <<+accurately+>> reflects the patient's history and <<-treatment->> <<+care+>>, where the written request comes from an insurance carrier or its agent with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement.

3. (No change.)

4. <<-If->> <<+A licensee may refuse to release a record to a patient if+>>, in the exercise of professional judgment, a licensee has reason to believe that the patient may be harmed by release of the subjective information contained in the patient record or a summary thereof<<-, the licensee may refuse to provide such information to the patient->>. <<- That->> <<+The+>> record or the summary, with an accompanying notice setting forth the reasons for the original refusal, shall nevertheless be provided upon request of and directly to:

i.-iii. (No change.)

5. (No change.)

(e) Licensees shall maintain the confidentiality of patient records, except that:

1. (No change.)

2. The licensee, in the exercise of professional judgment and in the best interests of the patient (even absent the patient's request), may release pertinent information about the patient's <<-treatment->> <<+care+>> to another licensed health care professional who is providing or who has been asked to provide <<-treatment->> <<+care+>> to the patient, or whose expertise may assist the licensee in his or her rendition of professional services.

3. (No change.)

(f) Where a third party or entity has requested examination or an evaluation of a person for a purpose unrelated to <<-treatment->> <<+care+>> by the examiner and where a report of the examination is to be supplied to the third party, the licensee rendering those services shall prepare appropriate records and maintain their confidentiality, except to the extent provided by this section. The licensee's report to the third party relating to the patient shall be made part of the record. The licensee shall:

1.-3. (No change.)

(g) If a licensee ceases to engage in practice or it is anticipated that he or she will remain out of practice for more than three months, the licensee or a designee shall:

1. Establish a procedure by which patients can obtain <<- treatment->> <<+patient+>> records or acquiesce in the transfer of those records to another licensee or health care professional who is assuming the responsibilities of that practice;

2.-4. (No change.)

<< NJ ADC 13:44E-2.3 >>

13:44E-2.3 Sexual misconduct

(a) (No change.)

(b) As used in this section, the following terms have the following meanings unless the context indicates otherwise:

1. (No change.)

2. "Patient" means any person who is the recipient of a professional service rendered by a licensee for the purposes of diagnosis, <<- treatment->> <<+care+>> or a consultation relating to chiropractic <<- treatment->> <<+care+>>. "Patient" for purposes of this section also means a person who is the subject of professional examination even if the purpose of that examination is unrelated to <<-treatment->> <<+ care+>>.

3. "Patient-<<-physician->><<+chiropractor+>> relationship" means an association between a <<-physician->> <<+chiropractor+>> and patient wherein the licensee owes a continuing duty to the patient to be available to render professional services consistent with his or her chiropractic training and experience. The performance of any professional chiropractic service includes, but is not limited to, any consultation, examination, and <<- treatment->> <<+care+>> provided by a licensee in furtherance of chiropractic <<-treatment->> <<+care+>> or consultation.

4.-6. (No change.)

(c) A licensee shall not engage in sexual contact with a patient with whom he or she has a patient-<<-physician->><<+chiropractor+>> relationship. The patient-<<-physician->><<+chiropractor+>> relationship is considered ongoing for purposes of this section, unless:

1. <<-Activity->> <<+Professional services are+>> terminated, by way of written notice to the patient and documentation in the patient record; or

2. (No change.)

(d) A licensee shall not seek or solicit sexual contact with a patient with whom he or she has a patient-<<-physician->><<+chiropractor+>> relationship and shall not seek or solicit sexual contact with any person in exchange for professional services.

(e)-(k) (No change.)

<< NJ ADC 13:44E-2.4 >>

13:44E-2.4 Chiropractor of record; fee reimbursement

(a) Each patient in a chiropractic facility shall have a chiropractor of record who shall remain primarily responsible for assuring the proper implementation of the chiropractic services to be rendered to such patient regardless of whether the services are rendered by the chiropractor of record or by any other person rendering chiropractic services or ancillary <<- treatment->> <<+care+>> to the patient.

(b) The name of the chiropractor of record shall be conspicuously identified on the patient record. If the chiropractor of record is not identified on the patient record, it shall be presumed that the chiropractor of record is the owner of the practice in which the patient <<-was treated->> <<+received care+>>.

(c) Each chiropractor or any other person rendering services shall sign or initial each entry on the patient record pertaining to the services he or she provided. If no such entry appears on the patient record, it shall be presumed that such service was rendered by the chiropractor of record, unless the <<- latter shall establish->> <<+chiropractor of record establishes+>> the identity of the individual who provided such services.

(d) In a multi-chiropractor practice, the chiropractor of record shall remain the <<-same->> <<+chiropractor for a patient+>> until a subsequent chiropractor affirmatively notes in the patient record that he or she is currently the chiropractor of record. In the event that the chiropractor of record leaves the practice, a successor chiropractor shall be designated if the patient elects to continue treatment in the facility.

(e) (No change.)

(f) Any <<-licensee->> <<+chiropractor+>> found to have rendered services in violation of N.J.S.A. 45:1-21 and the owner of the facility in which the licensee render such services shall be jointly and severally responsible for any restoration of patient fees as may be ordered by the Board.

<< NJ ADC 13:44E-2.5 >>

13:44E-2.5 Fee schedule

(a) The following fees shall be charged by the Board:

1. Application Fee ................................ $125.00

Recodify existing 3.-9. as <<+2.-8.+>> (No change in text.)

<< NJ ADC 13:44E-2.6 >>

<<-13:44E-2.6 (Reserved)->>

<< NJ ADC 13:44E-2.7 >>

<< NJ ADC 13:44E-2.6 >>

13:44E-<<-2.7->><<+2.6+>> Referral fees

It shall be professional misconduct for a licensee to pay, offer to pay, or to receive from any person any fee or other form of compensation for the referral of a patient. <<-The within prohibition->> <<+This section+>> shall not prohibit the division of fees among licensees engaged in a bona fide employment, partnership or corporate relationship for the delivery of professional services.

<< NJ ADC 13:44E-2.8 >>

<< NJ ADC 13:44E-2.7 >>

13:44E-<<-2.8->><<+2.7+>> Delegable tasks or functions of unlicensed assistants

(a) (No change.)

(b) Under the direct supervision of, and when delegated by, a licensed chiropractor, an unlicensed assistant, including a graduate of a recognized program of study in chiropractic, may perform tasks or functions including, but not limited to, the following:

1. Completing a medical history <<-with the->> <<+of a+>> patient;

2. Preparing the patient for chiropractic <<-treatment->> <<+care+>>;

3.-9. (No change.)

(c)-(f) (No change.)

<< NJ ADC 13:44E-2.9 >>

<< NJ ADC 13:44E-2.8 >>

13:44E-<<-2.9->><<+2.8+>> (No change in text.)

<< NJ ADC 13:44E-2.10 >>

<< NJ ADC 13:44E-2.9 >>

13:44E-<<-2.10->><<+2.9+>> Display of license

Each person holding a license to practice chiropractic in the State of New Jersey shall display the license and the current renewal certificate in a conspicuous place in his or her principal office or place of practice. In addition, the licensee shall display a <<-copy->> <<+duplicate issued by the Board+>> of the current renewal certificate in all other facilities where the licensee practices.

<< NJ ADC 13:44E-2.11 >>

<< NJ ADC 13:44E-2.10 >>

13:44E-<<-2.11->><<+2.10+>> (No change in text.)

<< NJ ADC 13:44E-2.6 >>

<<-13:44E-2.12 (Reserved)->>

<< NJ ADC 13:44E-2.13 >>

<< NJ ADC 13:44E-2.11 >>

13:44E-<<-2.13->><<+2.11+>> Overutilization; excessive fees

(a) A licensee shall not directly or indirectly engage in the rendering of any bill or the submission of any claim for service which:

1.-2. (No change.)

3. Represents multiple charges for the same chiropractic services or <<- treatments->> <<+care+>>, goods or appliances;

4. Contains an excessive fee. A fee is excessive when, after a review of the facts, a licensee of ordinary prudence would be left with a definite and firm conviction that the fee is so high as to be manifestly unconscionableor overreaching under the circumstances. The charging of an excessive fee shall constitute professional misconduct pursuant to N.J.S.A. 45:1-21. Factors which may be considered in determining whether a fee is excessive include, but are not limited to, the following:

i. (No change.)

ii. The novelty and difficulty of the procedure or <<-treatment->> <<+ chiropractic care+>>;

iii. The skill required to perform the procedure or <<- treatment->> <<+chiropractic care+>> properly;

iv.-vii. (No change.)

5. Is for services, goods or appliances which were not rendered or supplied; <<+or+>>

6. Is for a charge or claim which, due to the presence of insurance coverage, exceeds the usual and customary charges for such services, goods or appliances for patients who do not have insurance coverage<<-; or->><<+.+>>

<<-7. (Reserved)->>

<< NJ ADC 13:44E-2.14 >>

<< NJ ADC 13:44E-2.12 >>

13:44E-<<-2.14->><<+2.12+>> Referral of patients to physical therapists

(a)-(b) (No change.)

(c) After the physical therapist has completed the physical therapy examination and evaluation, the referring chiropractor shall <<-participate in consultation->> <<+consult+>> with the physical therapist<<-. This consultation shall->> <<+to+>>:

1. (No change.)

2. Coordinate <<+care and/or+>> treatment programs in the event that the patient receives concurrent chiropractic and physical therapy. Any such concurrent <<+care and/or+>> treatment programs shall be compatible; and

3. (No change.)

(d) (No change.)

<< NJ ADC 13:44E-2.15 >>

<< NJ ADC 13:44E-2.13 >>

13:44E-<<-2.15->><<+2.13+>> Chiropractic examination

<<-(a) From July 17, 2000 until December 31, 2000, to obtain a license to practice chiropractic, a candidate shall successfully pass:->>

<<-1. Parts I, II, III and IV of the National Board of Chiropractic Examiners Examination and a written jurisprudence examination administered by the New Jersey Board of Chiropractic Examiners; or->>

<<-2. Parts I, II and III of the National Board of Chiropractic Examiners Examination and an examination administered by the New Jersey State Board of Chiropractic Examiners consisting of:->>

<<-i. An objective imaging examination;->>

<<-ii. A written jurisprudence examination;->>

<<-iii. A case management examination; and->>

<<-iv. A technique examination.->>

Recodify existing (b)-(d) as <<+(a)-(c)+>> (No change in text.)

<<-(e) Subsection (a) above shall expire on December 31, 2000.->>

SUBCHAPTER 3. DETERMINATIONS WITH RESPECT TO THE VALIDITY OF CERTAIN DIAGNOSTIC TESTS, SPECIAL REQUIREMENTS FOR ELECTRODIAGNOSTIC TESTS AND OTHER SPECIAL EXAMINATIONS

<< NJ ADC 13:44E-3.1 >>

13:44E-3.1 Definitions

As used in this subchapter, the following words and terms shall have the following meanings, unless the context clearly indicates otherwise.

...

"Chiropractic physician" means a <<-chiropractic physician->> <<+ chiropractor+>> holding a license issued by the New Jersey State Board of Chiropractic Examiners.



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