How to Bill and Code Complex Chiropractic Conditions

How to Bill and Code Complex Chiropractic Conditions

Chiropractors treat a wide variety of conditions such as back pain, neck pain, herniated discs, sciatica, pinched nerves, and migraine as well as complex conditions. Many practices rely on Chiropractic Billing Services to report diagnosis and treatment accurately on claims. When it comes to billing and coding complex chiropractic conditions, proper documentation and using the right coding practices are essential to tell the whole story, communicate the findings, and prove medical necessity. Changes in the Evaluation and Management (E/M) rules and ICD-10 codes have made it easier for chiropractors to report complex conditions to insurers.

  • Office/Outpatient E/M Codes (new patient): In 2021, coding guidelines for outpatient E/M services were revised with the result that patient codes 99202-99205 do not require the 3 key components –patient history, clinical examination, and medical decision making (MDM) — or reference typical face-to-face time. Effective 2021, each of the services includes a “ medically appropriate history and examination,” and code selection is based on the level of MDM or total time spent on the date of the encounter. The provider can now document medically necessity to establish a diagnosis, evaluate the status of a condition, and recommend the appropriate treatment option.
  • ICD-10 codes to report complex conditions to the highest level of specificity: ICD-10 coding allow for specificity.
    • ICD-10 codes can indicate if the condition is on the right side or the left and if the condition is chronic or acute.
    • ICD-10’s seventh character is an extension that allows for documenting the phase of care for injuries and other conditions with external causes. The extension will indicate if the patient is in the active phase of care, the rehabilitation or healing phase, or is suffering from a sequela of the injury.
    • Providers can report all diagnosis codes that identify the patient’s condition to the highest degree of specificity.

By reporting the patient’s co-morbidities that impact their current diagnosis, chiropractors can demonstrate the necessity of the level of care provided for the complex condition.

  • Documentation: History, subjective complaints and objective findings should be clearly documented. This will allow the medical coder to assign specific diagnosis codes to describe the patient’s condition. For e.g., M54.2 Cervicalgia, M47 Spondylosis, and M54.5 Lumbago are non-specific ICD-10 codes commonly used in the chiropractic office. By documenting the reasons for the back or neck pain, more specific codes can be assigned to better report the patient’s health condition.
  • An article on offers the following guidance on documenting complex chiropractic conditions:

    • After conducting an examination, if it is decided that X-rays should be taken due to the presenting condition, the ordering and analysis of the X-rays would be considered in the complexity of the data to be reviewed and analyzed.
    • Ordering and prescription of proper custom orthotics would also be documented in the medical decision-making.
    • The nature of the mechanism of injury, the treatment options and the diagnoses are documented and if all these factors are rationally related in complexity, the care is considered to be medically necessary.
  • Order and placement of codes: When a chiropractor reports multiple diagnoses, the order of the codes will also impact claim adjudication, in addition to using the codes to their highest specificity. For instance, Medicare instructs that the precise level of the subluxation must be listed as the primary diagnosis. So, when required, segmental and somatic dysfunction (subluxation) codes (M99.1 – M99.05) should be always placed in the first position on the Medicare claim form. However, other commercial insurance and liability carriers may not require this. Sometimes, certain medical conditions are “complicated” by other disorders. In such situations, the order of the conditions present is crucial. The correct order in which they should be stated in the claim form is:
    • Neurologic conditions
    • Structural problems
    • Functional disorders
    • Complicating factors
  • Payer requirements: Changes and new requirements for Medicare and private insurance make chiropractic medical billing quite complex. In both cases, of course, chiropractors must provide evidence to support both standard and complex treatments. CMS guidelines state: “ The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for the treatments. The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s). There are five spinal regions addressed: cervical region (atlanto-occipital joint), thoracic region (costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region” (ref. CPT® Professional Edition 2017 p. 672). Further, Medicare guidelines state that a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation, and that the Modifier AT must not be used when maintenance therapy has been performed.

Private insurers also have specific guidelines for coverage of chiropractic services. For e.g., Aetna considers chiropractic services as medically necessary when all of the following criteria are met:

– The member has a neuromusculoskeletal disorder.

– The medical necessity for treatment is clearly documented.

– Improvement is documented within the initial 2 weeks of chiropractic care.

Partnering with an experienced chiropractic medical billing company is the best way for chiropractic practices to report complex conditions correctly and avoid claim denials and audits.

Does Medicare Cover Chiropractic Services?

Does Medicare Cover Chiropractic Services?

The American Chiropractic Association estimates that chiropractors see about 35 million people in the United States annually. Chiropractors typically treat musculoskeletal disorders such as back and neck pain, other conditions affecting the joints, ligaments and muscles, and headaches. Many practices rely on chiropractic billing services to get optimal reimbursement for spinal manipulation procedures and other treatments.

Chiropractic is an alternative for surgical treatment and pain medications. With many people 65 and older turning to chiropractic care, one question that comes up is: does Medicare cover chiropractic services? Let’s take a look at what chiropractic services Medicare covers and the codes to report these services.

Conditions for Medicare Coverage of Chiropractic Services states: “Medicare Part B (Medical Insurance) covers manual manipulation of the spine provided by a chiropractor or other qualified provider if medically necessary to correct a subluxation. Medicare doesn’t cover other services or tests a chiropractor orders, including X-rays, massage therapy, and acupuncture.”

This indicates that Medicare coverage of chiropractic services is available only for treatment by means of manual manipulation (using hands) of the spine to correct a subluxation. United Healthcare Medicare Advantage lists the conditions for Medicare coverage for chiropractic care as follows:

  • The patient must require treatment by means of manual manipulation of the spine to correct a subluxation.
  • The manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
  • Manual devices (those that are handheld with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine, but no additional payment is available for use of the device
  • The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for the treatments. The chiropractor must specify the precise level(s) of the subluxation(s) to support a claim for manipulation of each spinal region(s).
  • The need for an extensive, prolonged course of treatment should be appropriate to the reported procedure code(s) and must be documented clearly in the medical record.
  • An x-ray or any diagnostic test taken in order to determine or demonstrate the existence of a subluxation of the spine is covered if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.
  • Medicare coverage for treatment by means of manual manipulation of the spine to correct a subluxation will be provided only if such treatment is legal in the State where performed.

Use of the AT Modifier

The (AT) modifier is intended to distinguish between active treatment and maintenance treatment. Medicare pays for active/corrective treatment for acute or chronic subluxation and not for maintenance therapy.

  • The chiropractor must place an Active Treatment (AT) modifier on a claim submitted to Medicare when providing active/corrective treatment to treat acute or chronic subluxation.
  • Modifier AT must only be used when the chiropractic manipulation is “reasonable and necessary” as defined by national policy and the LCDs. Modifier AT must not be used when maintenance therapy has been performed.

UnitedHealthcare further states that the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary and that they may deny if appropriate after medical review.

ICD-10 Codes for Medicare Covered Chiropractic Services

Chiropractic service may be covered when CPT codes 98940, 98941, or 98942 are billed with one of the following primary diagnosis codes and with modifier AT:

M99.00 Segmental and somatic dysfunction of head region

M99.01 …cervical region
M99.02 … thoracic region
M99.03 …lumbar region
M99.04 …sacral region
M99.05 …pelvic region M99.10 Subluxation complex (vertebral) of head region

M99.11 …cervical region
M99.12 … thoracic region
M99.13 … lumbar region
M99.14 … sacral region
M99.15 … pelvic region

M99.20 Subluxation stenosis of neural canal of head region
M99.21 … cervical region
M99.22 … thoracic region
M99.23 … lumbar region

S13.100A Subluxation of unspecified cervical vertebrae, initial encounter

S13.110A Subluxation of C0/C1 cervical vertebrae, initial encounter
S13.120A Subluxation of C1/C2 cervical vertebrae, initial encounter
S13.130A Subluxation of C2/C3 cervical vertebrae, initial encounter
S13.140A Subluxation of C3/C4 cervical vertebrae, initial encounter
S13.150A Subluxation of C4/C5 cervical vertebrae, initial encounter
S13.160A Subluxation of C5/C6 cervical vertebrae, initial encounter
S13.170A Subluxation of C6/C7 cervical vertebrae, initial encounter
S13.180A Subluxation of C7/T1 cervical vertebrae, initial encounter

S23.100A Subluxation of unspecified thoracic vertebra, initial encounter

S23.110A Subluxation of T1/T2 thoracic vertebra, initial encounter
S23.120A Subluxation of T2/T3 thoracic vertebra, initial encounter
S23.122A Subluxation of T3/T4 thoracic vertebra, initial encounter
S23.130A Subluxation of T4/T5 thoracic vertebra, initial encounter
S23.132A Subluxation of T5/T6 thoracic vertebra, initial encounter
S23.140A Subluxation of T6/T7 thoracic vertebra, initial encounter
S23.142A Subluxation of T7/T8 thoracic vertebra, initial encounter
S23.150A Subluxation of T8/T9 thoracic vertebra, initial encounter
S23.152A Subluxation of T9/T10 thoracic vertebra, initial encounter
S23.160A Subluxation of T10/T11 thoracic vertebra, initial encounter
S23.162A Subluxation of T11/T12 thoracic vertebra, initial encounter
S23.170A Subluxation of T12/L1 thoracic vertebra, initial encounter

S33.100A Subluxation of unspecified lumbar vertebra, initial encounter

S33.110A Subluxation of L1/L2 lumbar vertebra, initial encounter
S33.120A Subluxation of L2/L3 lumbar vertebra, initial encounter
S33.130A Subluxation of L3/L4 lumbar vertebra, initial encounter
S33.140A Subluxation of L4/L5 lumbar vertebra, initial encounter

CPT codes 98940, 98941, or 98942 billed with specific primary diagnosis codes without modifier AT may be covered by Medicare if there is a supplemental chiropractic benefit.

Submitting claims for chiropractic services is easier with the support of a chiropractic medical coding expert.

Outsourcing companies providing chiropractic coding and billing services stay up to date with code changes, payer rules and guidelines, and state regulations and can help practices ensure accurate claims submission to improve their bottom line and overall efficiency.

What and How to Bill Chiropractic TeleHealth Services

What and How to Bill Chiropractic TeleHealth Services

When the novel coronavirus pandemic confined people to their homes, telemedicine proved a practical way for physicians to interact with patients and improve access to care. Recognizing the value of telehealth in these challenging times, the Centers for Medicare and Medicaid (CMS) expanded covered telehealth services to include 135 different services and went on to make many telehealth flexibilities permanent. Many payers are also reimbursing chiropractic services provided via telehealth, though knowing state, local and payer rules is crucial to submit accurate claims. Relying on chiropractic billing services provided by an expert can ensure proper billing and reimbursement.

Chiropractic Telehealth Services

Telehealth encompasses video/audio communication between the health care provider and patient which can be real time or recorded for evaluation at a later time. Chiropractic telemedicine or telehealth includes different types of online consultations and electronic communications between chiropractors and patients:

Synchronous communication: This includes real time videoconferencing such as video consultation/video visit/video encounter or standard telephone calls where there is a “two-way audiovisual link between a patient and a care provider”, states the Office of the National Coordinator for Health Information Technology (ONC).

Asynchronous communication: Defined as “store-and-forward video-conferencing,” by the ONC, asynchronous telemedicine involves data transfer takes place over a period of time, rather than simultaneously (such as secure patient messaging, forwarding of imaging results).

Telerehabilitation: Provision of clinical rehabilitation services using telehealth technologies, covering a range of services from evaluation and diagnosis, through patient care management.

Physical manipulations such as adjustments can be performed only if the patient is present in the chiropractor’s office. Then what are the services that chiropractors can provide via telehealth? Doctors of chiropractic can use telemedicine for communicating with patients to:

  • Discuss symptoms
  • Prescribe exercises
  • Modify behaviours that may be worsening pain
  • Provide advice on self-management strategies that can be done at home
  • Assess patient’s progress
  • Provide follow-up treatment
  • Answer patients’ questions

Coding and Billing Chiropractic Services provided using Telehealth

Telemedicine CPT codes 99421-99423 can be used to bill services provided to established patients who have not had an in-office E/M service billed by the same provider within the same seven-day period ( These telemedicine CPT codes are time-based should be billed as follows:

99421: Online digital E/M service for an established patient for up to seven days. Cumulative time: 5-10 minutes.
99422: Online digital E/M service for an established patient for up to seven days. Cumulative time: 11-20 minutes.
99423: Online digital E/M service for an established patient for up to seven days. Cumulative time: 21 or more minutes.

Telephonic E/M services (CPT codes 99441-99443) can be provided in cases where face-to-face visits may not be recommended, and it is medically appropriate for the patient to be evaluated and managed by telephone. However, telephonic services are to be provided only for the care of established patients or the legal guardian of an established patient.

Code “02” indicates that the E/M service was performed via telehealth. If the telemedicine visit is synchronous, modifier 95 should be appended to the code. However, it’s important to check payer rules as while some payers may prefer modifier 95, others may prefer modifier GT.

Telehealth services should be documented the same way as face-to-face services are documented. It should be stated that the service was provided non-face-to-face, and the patient’s location, the provider’s location, and the names and roles of anyone participating in the encounter should be included (

Like all medical billing, telehealth billing and reimbursement can be complex. Patients’ eligibility should be verified before the visit. Commercial insurance companies have different requirements billing telemedicine visits. Providers should ask payers about the CPT codes that can be used for telehealth billing. They should know specific payer telehealth policies and check with each payer before submitting claims to ensure compliance. Partnering with an experienced chiropractic billing company is the best way to ensure accurate claim submission and get paid promptly for telehealth services.

What Compliance Means for the Chiropractic Practice

What Compliance Means for the Chiropractic Practice

Compliance became a buzzword among chiropractors when the Office of Inspector General (OIG) formulated and published compliance program regulations for individual and small-group physician practices in October 2000. Voluntary compliance programs offer a way to prevent and reduce improper billing and coding conduct and protect the integrity of Medicare and other federal healthcare programs. In fact, chiropractic billing companies help providers ensure that the claims submitted to federal healthcare programs are true and accurate. However, for the chiropractors, sound compliance also includes maintaining proper documentation, performing a security risk analysis of their EHR, adhering to HIPAA rules and establishing medical necessity on claims. Let’s look at the implications of compliance for the chiropractic practice.

  • Proper coding: The chiropractic codes selected must correctly reflect the chiropractic care provided to the patient. Providers need to be up-to-date on ICD-10 and CPT coding to report services accurately. The newest ICD-10 code set for chiropractic which came into effect on October 1, 2018 includes updates for myalgia and muscular dystrophy. It is crucial to be as specific as possible when choosing the diagnosis code. CPT codes frequently used in chiropractic practices are include: manipulation: 98940-98943; Evaluation and Management, Initial Visit: 99202-99204; Evaluation and Management, Established Patient: 99212-99214; Therapeutic Exercises: 97110; Neuromuscular Re-education: 97112; Manual Therapy: 97140, and Physical Performance Examination: 97750. Chiropractors need to know the rules to bill these procedures. For instance, AAPC points out that chiropractors should not bill high-level codes such as 99204 and 99215 because the patients they see rarely have presenting problems to justify high level E/M encounters.
  • Proper documentation: The American Chiropractic Association (ACA) stresses the importance of completely documenting each patient encounter. While documentation may not be required for initial billing of services, it substantiates that the service was actually performed, which is important to prevent auditors from deducing that care was not provided appropriately.
  • MACRA: A 2016 article in Chiropractic Economics notes that MACRA (Medicare Access and CHIP Reauthorization Act of 2015) matters for compliance. Once registered as a Medicare provider, doctors of chiropractic cannot opt out like other physicians. To succeed with the new payment model, providers need to have the ability to report and stay complaint with the new system.
  • Compliance with HIPAA and other standards: The Health Insurance Portability and Accountability Act (HIPAA) is here to stay. Every practice should have clearly written standards and procedures for access of the patient records, (by patient, by other providers and by a third-party payer such as a chiropractic medical billing company) and authorizations required for access-HIPAA compliance. Similarly, there should be well-established procedures for documentation of informed consent, creation and preservation of treatment records, content of treatment records, and time frames for entry of data. All policies and procedures should be implemented on regular basis to ensure that patient encounters are properly documented, claims are billed properly to third-party payers, and all patient information is confidential and secure. Staff training is an important part of EHR security and protection against virus attacks. In addition, chiropractic practices must adhere to the standards of Occupational Safety and Health Administration (OSHA) to ensure a safe and healthful working environment for staff by setting and enforcing standards and to provide training, outreach, education, and assistance. Staff training is crucial to prevent injury and illness.
  • Medicare documentation: Both the OIG and the Centers for Medicare and Medicaid (CMS) insist on more stringent documentation standards for chiropractic physicians in an effort to ensure medically necessary treatment for Medicare beneficiaries. Chiropractors’ billing claims should clearly establish that the care they are providing is medically necessary. Medicare is a significant source of revenue for many providers. Generally, maintenance care is scrutinized more closely and will be denied outright by Medicare and some other payers if medical necessity is not established. So, doctors of chiropractic need to manage their Medicare documentation to promote legal and compliance protection and get appropriate financial compensation for their services.

The ACA recommends that chiropractors perform self-audits to avoid regulatory and commercial payer audits and recoupments. With self-audits, practices can confirm that services are properly documented and billed. A self-audit can be performed on a daily basis before services are billed, or on a monthly, quarterly, semi-annual, or annual basis. Audits can be performed on each chart for a particular date of service or occasionally for proper coding, documentation and compliance with insurer contracts. Medical billing outsourcing companies that specialize in chiropractic billing have stringent QA measures in place to ensure error-free claim submission.

Seven Strategies to Improve Chiropractic Medical Billing and Revenue

Seven Strategies to Improve Chiropractic Medical Billing and Revenue

With Medicare and private payer insurance changes and new requirements and regulations, chiropractic medical billing has become quite complex. In this dynamic scenario, chiropractors need to revamp their revenue cycle technologies and billing workflows to submit clean claims, reduce denials, and get reimbursed. Here are seven chiropractic billing strategies that can streamline a practice’s financial workflow and improve revenue.

  • Educate patients: Patients are facing higher deductibles and co-pays higher than ever before, but most are unschooled in these aspects and other chiropractic medical billing and insurance terminology. With patients being more responsible for their own healthcare costs, it’s important to initiate conversations with them about cash. A recent JAMA Internal Medicine study found that the percentage of hospitals that are not able to give consumers price estimates increased from 14 percent in 2012 to 44 percent in 2018. According to a Revenue Cycle Intelligence report, to improve the patient financial experience, providers should inform patients of their financial responsibility before their office visit. Patients should understand the costs involved with chiropractic care, what their insurance covers, and what their financial responsibilities could be. A Medical Economics article suggests that patients be given a flyer with a simple explanation of billing basics. They can be directed to a customer service number for issues that need clarification. Make sure office staff knows how to communicate with patients about billing information.
  • Verify insurance: Billing success begins at the front desk. Insurance verification should be done at each visit to understand what the patient’s responsibility is. Carriers offer different plans with varying deductibles and copay options. Getting insurance eligibility verification done by a specialist before the office visit would ensure that both the provider and the patient know how much the patient is responsible for and what’s covered. It’s important to check eligibility for returning patients who have been absent a while. Recording accurate patient data, including insurance information and provider eligibility, is necessary for error-free claims submission.
  • Analyze and optimize accounts receivable (A/R): “Days in A/R” refer to the average number of days it takes to collect the payments due to the practice. The lower the number of days, the faster the practice is obtaining payment, on average. Physicians Practice recommends keeping your accounts receivable in the 0-30 day category. Evaluating A/R will help you determine whether your practice’s revenue management cycle processes are efficient and effective, and address any issues preventing timely payments. Here are some tips to optimize A/R management:
    • Separate insurance and patient accounts receivable
    • Understand how each payer’s specific guidelines affect your A/R management
    • Establish relationships with each payer as this can help resolve problems faster
    • Analyze reimbursement trends by payer on a monthly basis to identify, evaluate and prioritize the risks
    • File claims on the day of service
    • Implement a strict collections policy for patient accounts
  • Even if you have a medical billing company handling your revenue cycle management, chiropractors need to maintain constant awareness to manage their A/R processes.
  • Review insurance contracts: Practices need to take time to review their contracts with payers to understand if there were any changes from the previous year. This will allow them to take steps to plan for any renotiations, accommodate a change in workflow and processes, and retrain staff if necessary. Providers should also be aware of all filing deadlines for the year ahead.
  • Code correctly: Clean claim submission depends to a large extent on accurate coding. With ICD-10, chiropractors can use more specific codes to report diagnosis and using the right codes can prevent claim denials and ensure appropriate reimbursement. They must also use the right chiropractic procedure codes and modifiers to report services rendered correctly. Incorrect coding will attract unwanted scrutiny and also affect revenue.
  • Ensure appropriate documentation: Among the four major types of documentation errors (no documentation, insufficient documentation, lack of medical necessity, and incorrect coding), the Department of Health and Human Services Office of Inspector General (OIG) found that improper payment rates attributed to insufficient documentation rose from 39.5% in 2010 to 92.2% in 2014 ( Each patient encounter should be clearly documented to prove that the service was actually performed.
  • Collect copays: To collect copays, have an established financial policy in place. Patients should sign a form acknowledging that their insurance may not cover all of their care. They can be offered flexibility and payment options to facilitate payment for all services and products as and when they are provided.

Practices that find it difficult to streamline their revenue cycle management can rely on an experienced chiropractic medical billing company to do so. Using the practice’s billing software or their own, an experienced outsourcing company can help chiropractic practices streamline their financial process and improve their revenue.

Clear Up Your Misconceptions about CMS’ Chiropractic Billing

Clear Up Your Misconceptions about CMS’ Chiropractic Billing

Running a successful chiropractic office also requires a clear understanding of coverage standards of Medicare or other private payers and how to bill for those services. Chiropractic offices as well as medical billing companies should stay up to date with the billing and coding changes as well, as improper billing can not only result in claim denial but may also lead to penalties. A real example for this discussed in The Gazette, is the case of an Oelwein chiropractor, who has agreed to pay $79,919 to resolve allegations of improper Medicare and Medicaid billing in March 2018. This chiropractor is alleged to have violated the False Claims Act by improperly billing Medicare and Medicaid for chiropractic adjustments after providing free electrical stimulation.

CMS’ Fact Sheet explains that it covers only manual manipulation of the spine by chiropractors. No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered. Even though orders for performing X-rays or other diagnostic tests can be used for claims processing purposes, Medicare does not cover them when performed by chiropractors. It is also recommended that claims must include a primary diagnosis of subluxation and a secondary diagnosis reflecting the patient’s neuromusculoskeletal condition. The patient’s medical record must support the services submitted.

Misconceptions and Facts

The Centers for Medicare & Medicaid Services (CMS) has clarified certain common misconceptions and facts related to chiropractic billing.

In performing manual manipulation of the spine, some chiropractors use manual devices that are handheld with the thrust of the force of the device being controlled manually. While such manual manipulation may be covered, there is no separate payment permitted for use of this device.

  1. There is a limit on the number of therapy caps for chiropractic services.
    Fact – Medicare Benefit Policy Manual, Chapter 15, Section 30.5 explains that there are actually no limits or caps in Medicare for covered chiropractic care provided by chiropractors, as long as they meet Medicare’s licensure and other requirements.
  2. Non-participating (non-par) providers do not have to worry about billing Medicare.
    Fact – Whether you are a non-participating (non-par) provider or not, all Medicare covered services must be billed to Medicare, or the provider could face penalties. This is referred to as Mandatory Claim Submission Rule. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. However, their Medicare reimbursement is five percent less than a participating provider.
  3. As a non-participating (non-par) provider, you will never be audited nor have claims reviewed
    Fact – Any Medicare claim submitted can be audited or reviewed, irrespective of the nonparticipating (non-par) or participating (par) status of the physician. CMS audits/reviews aims at identifying billing errors. Correct coverage, reimbursement, and billing requirements are readily available to help providers understand Medicare requirements.
  4. You can opt out of Medicare
    Fact – Opting out of Medicare is not an option for Chiropractic doctors. Opting out is entirely different from being non-participating. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out. By opting out, physicians will be able to decide not to bill Medicare at all and then enter into private contracts with Medicare beneficiaries they treat.
  5. Get an Advance Beneficiary Notification (ABN) signed once for each patient, and it will apply to all services, all visits
    Fact – To deliver an ABN, there must be a genuine reason like – Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The ABN then allows the beneficiary to make an informed decision about receiving and paying for the service. If the beneficiary decides to receive the service, providers must submit a claim to Medicare even though you expect the beneficiary to pay and you expect that Medicare will deny the claim. 

    According to CMS, an ABN is issued each time a patient receives a Medicare covered service that the provider believes might be considered not medically reasonable and necessary and thus not payable by Medicare. A single ABN can be issued to a patient receiving the same service multiple times on continuing bases. ABNs for repetitive services must describe the specific service(s) and frequency of delivery. A new ABN must be issued, if delivery of the repetitive service exceeds one year or the service provided changes.

  6. Maintenance care is not a covered service under Medicare
    Fact – As per Chapter 15, Section 30.5.B. of the Medicare Benefits Policy Manual, maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. Though spinal manipulation is a covered service under Medicare, maintenance care is not medically reasonable and necessary and therefore not reimbursable by Medicare. Acute, chronic, and maintenance adjustments are all “covered” services, but only acute and chronic services are considered active care and may, therefore, be reimbursable.
  7. Non-par providers do not have the same documentation requirements as par providers
    Fact – Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements. Required documentation also includes Evaluation and Plan of Care, Certification and re-certifications, Progress Reports, Treatment notes for each treatment day and more.
  8. DME ordered by a DC will be reimbursed by CMS
    Facts – A chiropractor may act as supplier of durable medical equipment (DME) if s/he has a valid supplier number assigned by the National Supplier Clearinghouse, but a chiropractor will not be reimbursed if s/he orders DME.

As Medicare only pays for active treatment of acute or chronic subluxations, it is important to submit claims for active treatment with HCPCS modifier AT. But Medicare does not cover maintenance therapy; do not submit claims for maintenance therapy with HCPCS modifier AT. However, there is hope for more chiropractic treatments to get Medicaid coverage. There were reports that in June 2018, a bill was approved by Missouri Legislature that would allow Medicaid patients to get treated by a chiropractor, a service that is not currently available to them. The measure will help ease the opioid crisis and save the state millions of dollars by offering a less expensive alternative to Medicaid recipients with back pain.

A recent study published in JAMA Network Open has found that expanding beneficiary access to non-pharmacological treatments such as physical therapy, chiropractic, and acupuncture services may allow payers to provide clinically-proven solutions for temporary pain without relying on opioid prescriptions. Chiropractic billing services help to improve the revenue cycle for chiropractors by submitting accurate claims for all their services such as examinations and evaluations, adjustments and manipulation of the spine, and pain management.