Unofficial Opinion 2006-1
Senator, District 26
Pursuant to O.C.G.A. § 43-9-12.1, a chiropractor, duly licensed and properly practicing in the state of Georgia, can refer a patient for X-rays or magnetic resonance imaging if the referral is needed to determine appropriate chiropractic care or for treatment for or evaluation of conditions which are outside the scope of practice of the chiropractor, assuming the referral is otherwise prudent and proper. This opinion supersedes 1993 Op. Atty Gen. 93-11.
You have asked whether a chiropractor, duly licensed and properly practicing in the state of Georgia, can refer a patient for X-rays or magnetic resonance imaging (MRI) if such a referral is otherwise prudent and proper. In 1993 Op. Att’y Gen. 93-11, prior to the enactment of O.C.G.A. § 43-9-12.1, this office concluded that referring patients for MRI was not within the scope of the practice of chiropractic in the state of Georgia. This conclusion was based on the fact that chiropractic involves the making of adjustments, and that “MRI is a diagnostic tool rather than a therapeutic one, and, therefore, is not utilized to make . . . adjustment[s].”1 To the extent that 1993 Op. Att’y Gen. 93-11 concludes that MRI referral is outside the scope of practice of chiropractic, it has been superseded by O.C.G.A. § 43-9-12.1, which makes referral necessary when appropriate in the determination of chiropractic care.
In 1997, after the issuance of 1993 Op. Att’y Gen. 93-11, O.C.G.A. § 43-9-12.1 was enacted. It provides:
The doctor of chiropractic must bring to the exercise of that person’s profession a reasonable degree of care and skill, which shall include the determination of the need for chiropractic care, as defined in paragraph (2) of Code Section 43-9-1, and shall render treatment, referral to the appropriate health care provider, or both treatment and referral commensurate with that chiropractor’s findings. Any failure to refer to the appropriate health care provider may subject the doctor of chiropractic to the provisions of Code Section 43-9-12. Nothing in this Code section shall be deemed to expand or limit the chiropractic scope of practice.
O.C.G.A. § 43-9-12.1 (2005) (emphasis added).
This provision requires chiropractors to refer when appropriate. It establishes a standard of care, and includes making referrals as part of the reasonable standard of care. Referral is not mentioned elsewhere in the law; however, it is addressed by rule by the Board of Chiropractic Examiners (hereinafter “Board”), which provides that “[t]he doctor of chiropractic has the responsibility as a primary health care provider to examine, establish a diagnosis/clinical impression, render treatment and/or referral, commensurate with his/her findings.” GA. COMP. R. & REGS. 100 10 .01 (2002). This language emphasizes that a chiropractor has a responsibility to render a referral in appropriate cases.
A patient may be referred for two distinct purposes. The referral may be for treatment for or evaluation of conditions which are outside the scope of practice of the chiropractor but within the scope of practice of another licensed health care provider. A second purpose of referral is for diagnostic procedures outside the referring provider’s scope of practice in terms of knowledge, expertise, instrumentation, or technology to determine the need for or appropriateness of further care that is within the referring provider’s, i.e., chiropractor’s, scope of practice. This would include a referral for an MRI or X-ray2, the results of which the chiropractor can use to determine “the need for chiropractic care" as O.C.G.A. § 43-9-12.1 requires.
I note that there is a distinction between referring for a diagnostic procedure such as MRI and ordering such a procedure. The law permits a chiropractor to refer when appropriate. The referral would necessarily be to a diagnostic practice group with a health care professional such as a radiologist trained to read, evaluate, and report on the images. I am informed by the Board that this is the actual practice since enactment of the 1997 amendment. So long as the referral is made under these circumstances, the chiropractor is acting within the scope of current Georgia law.
Therefore, it is my unofficial opinion that pursuant to O.C.G.A. § 43-9-12.1, a chiropractor, duly licensed and properly practicing in the state of Georgia, can refer a patient for X-rays or magnetic resonance imaging if the referral is needed to determine appropriate chiropractic care or for treatment for or evaluation of conditions which are outside the scope of practice of the chiropractor, assuming the referral is otherwise prudent and proper. This opinion supersedes 1993 Op. Att’y Gen. 93 11.
Assistant Attorney General
1 Although the opinion did not address the question whether a chiropractor could refer for X-rays, it did note that state law included within the definition of “Chiropractic” “the use of electric X-ray photography, provided that the X-ray shall not be used for therapeutical purposes.” 1993 Op. Att’y Gen. 93-11 at 30 (emphasis added). Even before the 1997 amendment, chiropractors were authorized under state law to X-ray patients. A fortiori, and for reasons set forth in this opinion, referral for X-rays would also be permitted under appropriate circumstances.
2 See note 1 supra. Georgia law specifically authorizes chiropractors to perform X-rays for non-therapeutic purposes.