Who Can Perform Spinal Manipulation? Scope, Training and Billing

Written by Dr. Larry Smith, DC, APRN

Updated September 2026 ·8 min read

Spinal manipulation is one of the few procedural skills a nurse practitioner or physician assistant can add without new equipment, a procedure room or imaging. The obstacle is usually not capability but uncertainty about whether it is permitted.

The answer, in the teaching of Dr. Larry Smith, DC, APRN, is more permissive than most clinicians assume — with one condition that does all the work.

The Medicare position

Smith states it plainly: Medicare holds that nurse practitioners and physician assistants “can perform any procedure otherwise reserved for physicians so long as it's within your state's scope of practice.”

That is a deferral rather than a permission. Medicare does not maintain its own list of procedures by profession; it points at the state. Which means the question is never “does Medicare allow this” but “does my state scope include it.”

The state scope question

On that, Smith is emphatic for nurse practitioners: “for the NPs out there, I will tell you it's in your state scope. It's in all 50. It'll say that you can perform it if you've been trained to do it.”

The consistent qualifier across those statutes is training, not profession. Scope language typically permits procedures the clinician is trained and competent to perform, rather than enumerating every procedure by name.

Physician assistants generally practise under a similar structure, with the supervising or collaborating physician relationship shaping what is delegated.

Osteopathic physicians are in a different position entirely — manipulation is taught in osteopathic medical school, so it is part of the base training rather than an addition.

The clause that actually governs

If you have been trained to do it.

That phrase is doing all the work in the paragraph above, and it is worth being honest about what it means. Scope of practice establishes that you may. It says nothing about whether you can, and the two are separate questions that get conflated constantly.

Manipulation is a physical skill. It depends on positioning, on palpating the segment, on the direction and amplitude of a thrust, and on knowing when not to deliver one. None of that is learned from a written description, which is why this guide contains no technique instruction.

Smith's course objective is framed around exactly that: proper body positioning and biomechanics “needed in order to deliver a high velocity, low amplitude manipulation to the lumbar spine”, taught with pre-manipulative positioning, the thrust manoeuvre and live demonstration.

Who the training is designed for

Smith's course is written specifically for “nurse practitioners, physician assistants and medical doctors, those who don't currently use manipulation in their practice to help their low back patients.”

That framing matters. It is not a chiropractic course delivered to non-chiropractors. It is manipulation taught to clinicians who already assess and manage low back pain and who want one more tool for it — which is why the contraindications and the coding get as much time as the technique.

Smith's own background is the argument for the approach: a chiropractor and nurse practitioner who spent 25 years in private practice and now works in a spine and sports medicine clinic practising interventional pain, using manipulation daily.

Getting paid for it

Scope permits the procedure; coding determines whether it is reimbursed. Smith teaches both, on the grounds that “as a provider, you need to know what you do and how to get paid.”

The manipulation codes are the osteopathic manipulative treatment series, selected by number of body regions treated. Lumbar spine, sacrum and pelvis is three or four regions. The series extends to ten, though he notes that even manipulating a patient head to toe he rarely reaches ten — usually seven or eight.

Three requirements decide the claim:

1. Primary diagnosis must be back pain. Vertebrogenic low back pain is M54.51.
2. The claim form carries only four diagnoses. The four that matter must be the four listed.
3. An office visit billed alongside needs a 25 modifier, indicating a separate procedure was performed in addition. He also notes a level-two visit code is too low to be useful for this work.

Verify locally. Payer policy varies and this is not a substitute for checking.

What permission does not cover

Being permitted to manipulate carries the obligation to know when not to.

Smith puts as much weight on that as on technique: “we also have to know what not to do for them. Know when you're out over your skis.” Cauda equina syndrome, definitive motor weakness, electric radicular pain to the foot, severe osteoporosis, and the systemic pathology that presents as back pain — kidney infection, tumour, colon and gynaecological cancers — all sit in that category.

His instruction is to practise medicine first: “Be a clinician. Is it an infection? Treat it.” Those are covered in contraindications and red flags.

Adding it to a practice

1. Read your own state scope language. Look for the training-and-competence clause rather than a list of named procedures.
2. Get trained hands-on. Positioning and thrust are not learned from text.
3. Learn the screening first. Knowing who not to treat is the part that protects both of you.
4. Set up the coding before the first patient, including the 25 modifier convention.
5. Document the examination that justified it, and the response.

Empire teaches the technique, screening and coding together across the pain management academy.