Chiropractic billing uses a smaller code set than almost any other specialty, and the coverage rules wrapped around those few codes are what make it difficult. Medicare pays a chiropractor for spinal manipulation only, only during active treatment, and only with a subluxation diagnosis in the primary position. Commercial plans cap visits, bundle the therapies, and often hand the whole benefit to a chiropractic network with its own review process. Our chiropractic billing services do the work of showing the visit was covered before the payer decides it was not.
The AT modifier, active treatment and maintenance care
Medicare covers 98940, 98941 and 98942 when the patient is under active treatment, meaning there is a reasonable expectation that the condition will improve, or that continued care will arrest a deteriorating one. The AT modifier on the claim is the practice's statement that the visit meets that standard. Once the patient has reached maximum improvement and care is keeping them where they are, the visit is maintenance, Medicare does not pay for it, and AT does not belong on the claim.
Maintenance visits billed to Medicare for a secondary plan's denial go out without AT and with GA if the patient signed an Advance Beneficiary Notice. The GA is what makes the denial a patient balance rather than a contractual write-off. We check the treatment plan dates and the documented progress before assigning AT, because a review that finds AT on maintenance visits is a review that asks for money back.
Diagnosis coding and the initial-treatment date
Medicare requires a segmental and somatic dysfunction code from M99.01 through M99.05 as the primary diagnosis, one for each spinal region treated, with a secondary neuromusculoskeletal diagnosis supporting the need for care in that region. The number of regions the diagnoses cover has to match the code billed: a 98941 for three to four regions with a single M99 code is a CO-11 waiting to happen.
Item 14 of the claim carries the date of the initial treatment or the exacerbation that began the current episode, which Medicare uses to judge how long the episode has run. The note has to show the subluxation by examination under the PART criteria. We verify that the regions, the diagnoses, the code level and the Item 14 date agree with one another on every Medicare claim before it goes.
What Medicare will not pay a chiropractor for
Everything a chiropractor does other than manual manipulation of the spine is excluded from Medicare coverage by statute: examinations, x-rays, therapeutic exercise, manual therapy, traction, electrical stimulation, extremity adjustments and supplies. They are never covered when a chiropractor performs them, and the patient is responsible for them. When they are billed to Medicare to obtain a denial for a secondary payer, they carry the GY modifier so the denial is clean and quick.
The practical problem is the front desk. A Medicare patient who receives an adjustment and fifteen minutes of therapeutic exercise owes for the exercise no matter what the claim says, and if that is not explained beforehand the practice either absorbs it or argues about it. We build the excluded services into the patient estimate so the conversation happens at scheduling.
Commercial plans, network managers and the therapy codes
Commercial chiropractic benefits usually come with an annual visit limit, often shared with physical and occupational therapy, and sometimes an authorization requirement after a set number of visits. Many plans delegate the benefit to a network manager such as American Specialty Health, which runs its own clinical review, provider tiering and claim address. The patient's card names the health plan; the payer that adjudicates the visit is the network.
The therapy lines are where commercial claims get thin. Therapeutic exercise, 97110, is timed and needs its minutes in the note; traction, 97012, and unattended electrical stimulation, 97014 or G0283 by payer, are one unit per visit, and many plans pay only a set number of modalities per date. Extraspinal manipulation, 98943, pays with an extremity diagnosis, but some plans bundle it into the spinal adjustment. Manual therapy, 97140, is bundled into CMT under NCCI unless it is performed on a separate region and billed with modifier 59. An E/M on the same day as an adjustment pays only for a new problem or a significant change, and billing 99213-25 on every visit is the fastest way a chiropractic practice gets flagged.
Chiropractic billing when half the practice is cash
Most chiropractic practices are a mix: insured patients, cash patients on a wellness plan, and personal injury patients whose bills are going to an auto carrier or an attorney. Medicare requires that covered manipulation be billed to Medicare even by a non-participating provider, so a Medicare patient cannot simply be moved to the cash plan for covered visits. Personal injury claims go to the auto or liability carrier with the accident date and are not health plan claims at all; sent to the health plan, they return as CO-109.
We keep the three populations separate in your practice management system so that health plan claims, personal injury balances with lien documentation, and cash memberships are each tracked and reported on their own terms. The fee schedule stays consistent across them, which matters when a payer audits what cash patients were charged.
Documentation that survives a review
Chiropractic claims are reviewed often, and the reviewers look at the same things each time: whether the treatment plan states goals, frequency and duration; whether progress is measured with something objective rather than "patient reports feeling better"; whether the region count and diagnoses match the code; and whether the visit was active treatment or maintenance. We read notes against that list on a sample at the start of the engagement, as a coding audit, before denials arrive.
When a payer requests records, the response goes out with the policy language the payer applied, the treatment plan and the notes for the dates in question, not the whole chart. Where denials trace back to a documentation habit, the fix is a conversation with the clinician about the template. Filing deadlines are tracked per payer too: Medicare allows twelve months from the date of service, many chiropractic networks far less.
Codes and Modifiers We Watch in Chiropractic
The codes that most often decide whether a chiropractic claim pays.
| Code | What it is | What goes wrong |
|---|---|---|
| 98940 | Chiropractic manipulative treatment, spinal, 1–2 regions | Requires an M99 subluxation diagnosis for each region treated; the only family of codes Medicare pays a chiropractor for. |
| 98941 | Chiropractic manipulative treatment, spinal, 3–4 regions | Denied as CO-11 when fewer diagnoses than regions are on the claim. Payers also compare the level billed against the note’s region list. |
| 98942 | Chiropractic manipulative treatment, spinal, 5 regions | Billed on every visit it draws review; the note has to document findings in all five regions each time. |
| 98943 | Chiropractic manipulative treatment, extraspinal, one or more regions | Never covered by Medicare. Commercial plans pay it with an extremity diagnosis, and several bundle it into same-day spinal CMT unless the note supports the separate region. |
| Modifier AT | Active treatment for acute or chronic subluxation | Required on Medicare CMT claims for payment. Left on maintenance visits it becomes an overpayment; left off active visits the claim denies. |
| Modifier GA, Modifier GY | ABN on file; item statutorily excluded | GA shifts a maintenance-care denial to the patient. GY marks exams, x-rays and therapies a chiropractor bills to Medicare only to obtain a denial. |
| M99 series | Segmental and somatic dysfunction by spinal region | Medicare primary diagnosis, one per region, paired with a secondary diagnosis such as a strain or radiculopathy supporting care in that region. |
| 97140 | Manual therapy, each 15 minutes | Bundled with CMT under NCCI unless performed on a separate region and billed with modifier 59; the region has to be named in the note. |
| 97110 / 97012 / G0283 | Therapeutic exercise, mechanical traction and unattended electrical stimulation | 97110 is timed and needs the minutes in the note; 97012 and G0283 are one unit per visit. Commercial plans often cap the number of modalities paid per date. |
| 99203, 99213 with modifier 25 | E/M on the same day as manipulation | Payable only for a new problem or a significant change evaluated separately from the adjustment. Routine use on every visit is a review trigger. |
Common Chiropractic Denials and How We Fix Them
- CO-50
Medicare manipulation denied as not medically necessary: AT missing, the diagnosis not a subluxation code, or the episode running long enough that the reviewer treats it as maintenance.
FixAT assigned only after the treatment plan and documented progress are checked; M99 primary with a supporting secondary diagnosis on every line; long episodes reviewed for a new exacerbation date or transition to ABN and GA.
- CO-170
Therapy, exam or x-ray billed to Medicare by a chiropractor denied as not payable when performed by this provider type.
FixStatutorily excluded services billed with GY only when a denial is needed for a secondary payer; otherwise collected from the patient as explained at scheduling.
- CO-119
Visit denied because the plan’s annual chiropractic allowance, often shared with physical therapy, is exhausted.
FixRemaining visits pulled at eligibility and displayed on the patient record; the patient is told before the visit that will not be covered, and the cash rate applies from that visit.
- CO-97
Manual therapy denied as included in the same-day manipulation.
FixBilled only when the note names a region separate from the adjusted regions, with modifier 59; where the note does not support it, the charge is removed before submission rather than appealed after.
| Medicare chiropractic coverage | Manual manipulation of the spine to correct a subluxation; all other chiropractor services excludedSource: CMS, Medicare Benefit Policy Manual, Chapter 15 |
|---|---|
| NCCI edits | Manual therapy (97140) bundled with chiropractic manipulation unless a distinct region is documentedSource: CMS, National Correct Coding Initiative |
Chiropractic Billing: Common Questions
Medicare requires covered manipulation to be billed, and a maintenance visit is billed without AT so the payer denies it correctly. With a signed ABN and the GA modifier, that denial becomes a patient balance you can collect. Without the ABN, the denial is your write-off.
Because the National Correct Coding Initiative bundles manual therapy into chiropractic manipulation. It pays separately only when it is performed on a region the adjustment did not address, the note names that region, and modifier 59 is on the line. If the note cannot support that, the charge should not go out.
The network, not the health plan, becomes the payer for those visits. It has its own payer ID, its own authorization or treatment-plan submission process and its own provider tiers. We verify at eligibility which network manages the benefit and bill and follow up with that organization directly.
Yes. Those balances are tracked separately from health plan claims, with the accident date, the carrier or attorney contact and the lien documentation on the account, and followed up as their own queue. They are not sent to the health plan, which would deny them as another payer’s responsibility.
No. Medicare covers manual manipulation of the spine only, so 98943 is excluded no matter the diagnosis. Many commercial plans do pay it when the note carries an extremity diagnosis and documents the region separately from the spinal adjustment, and we verify that benefit before it is billed.