Chiropractic Billing Compliance: Key Takeaways From Cms Article A56273

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Chiropractic services are gaining recognition as an effective, non-invasive treatment option for musculoskeletal conditions. This is especially true among Medicare beneficiaries, many of whom are seeking alternatives to drugs and surgery. However, with this growing demand comes greater responsibility for providers. In 2025, chiropractic providers, office managers, and medical billers face a rapidly shifting billing landscape shaped by evolving payer policies, increased Medicare scrutiny, and higher claim denial rates.
To stay compliant, chiropractors must stay up to date with Medicare billing standards. The Centers for Medicare & Medicaid Services (CMS) Article A56273 serves as a critical reference, offering clear guidance on documentation, service eligibility, and coding rules. Below are the essential takeaways for chiropractic billing compliance in 2025.
Compliance of Chiropractic Billing & Coding Guidelines
1. Coverage Rules
Medicare only reimburses medically necessary chiropractic services for the active treatment of spinal subluxation (partial spinal misalignment). These treatments must target ...
... a specific health issue—not routine care or wellness. Services such as acupuncture, massage therapy, or general checkups are excluded, even if provided in a chiropractic office.
2. Basic Billing Requirements
Chiropractors must follow Medicare billing rules carefully to receive payment. This includes using the correct CPT codes, applying modifiers when required, and submitting accurate claims on the CMS-1500 form for outpatient care.
3. Common CPT Codes
For spinal manipulation, use CPT codes:
• 98940: 1–2 spinal regions
• 98941: 3–4 regions
• 98942: 5 regions
Only services performed by Medicare-approved provider types may be billed (e.g., X-rays, massage, or PT cannot be billed by chiropractors under Medicare).
4. Documentation Requirements
Thorough documentation is critical for Medicare approval. Chiropractors must record a detailed initial exam, including history, symptoms, and physical findings. A subluxation diagnosis must be supported by an exam or prior X-rays. Each visit must include progress notes that show measurable improvement or changes in condition.
5. Modifiers in Chiropractic Billing
Correct use of modifiers helps prevent claim denials.
• AT: Active treatment of acute/subacute conditions (required for payment).
• GA: Patient agrees to pay for a service Medicare may deny.
• GX: Voluntary services not usually covered.
Claims missing proper modifiers are often rejected.
6. Billing for Exams (E/M Services)
If a chiropractor performs an exam separate from spinal manipulation, it may be billed as an Evaluation and Management (E/M) service (99202–99215). However, documentation must show it is distinct from manipulation. Use the -25 modifier to confirm that the E/M service is separate when billed on the same day.
7. Correct Coding Initiative (CCI)
The CCI edits prevent billing for combinations of services that should not be reported together. Chiropractors should review the latest edits regularly to ensure billing accuracy and avoid denials.
8. Local Medicare Administrative Contractors (MACs)
Rules can differ by region. Chiropractors must check their local MAC’s Local Coverage Determination (LCD) for region-specific coverage and billing guidelines.
9. Compliance & Internal Audits
To avoid repayment demands or audits, providers should conduct internal reviews of billing and documentation. Maintaining a written compliance plan and outsourcing to reliable offshore medical billing and coding services in India can strengthen billing accuracy and compliance.
10. Medicare Benefit Policy Manual
The Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 240 is the official guide for chiropractic care. It outlines documentation requirements, covered services, and medical necessity standards. This manual, available on the CMS website, should be reviewed frequently.
11. Advance Beneficiary Notice (ABN)
If a service may not be covered, chiropractors must provide patients with an ABN form before treatment. This ensures the patient understands their financial responsibility. Failure to issue an ABN may result in the chiropractor bearing the cost.
12. Visit Limitations
Medicare typically covers up to 12 chiropractic visits annually, provided medical necessity is documented. Additional visits may be approved if clinical notes demonstrate measurable progress such as pain reduction, improved mobility, or return to work.
13. Medicare as a Secondary Payer
When Medicare is not the primary payer, chiropractors must follow Medicare Secondary Payer (MSP) rules. Claims must be billed to the primary insurance first, with Medicare covering the remainder as appropriate. Skipping MSP checks may cause denials.
Conclusion
Chiropractic billing under Medicare requires precision, documentation, and compliance with CMS guidelines. By mastering documentation, using the correct CPT codes, applying modifiers properly, and monitoring local MAC policies, providers can significantly reduce claim denials and safeguard revenue.
Proactive steps—like regular compliance audits, referencing the CMS Article A56273, and consulting the Medicare Benefit Policy Manual—ensure providers remain compliant. For additional support, outsourcing medical billing and coding services providers in India with trusted partners like Info Hub Consultancy Services can streamline processes, improve accuracy, and strengthen financial performance.
FAQs
1. Can chiropractors bill for X-rays under Medicare?
No, Medicare does not reimburse chiropractors for X-rays, even if used for treatment planning.
2. What is the biggest reason for chiropractic claim denials in 2025?
Failure to document subluxation with a treatment plan is the leading cause of denials.
3. Are maintenance chiropractic visits covered by Medicare?
No, maintenance therapy is not considered medically necessary and is not covered.
4. Can chiropractors bill for telehealth services?
No, chiropractic services must be provided face-to-face and cannot be billed as telehealth.

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