Medicare Chiropractic Billing Guide - Simplifying Reimbursement for Chiropractic Services

Medicare Chiropractic Billing Guide – Simplifying Reimbursement for Chiropractic Services

As the healthcare landscape continues to evolve, chiropractic care has emerged as a valuable treatment option for many individuals seeking non-invasive alternatives to traditional medical interventions. Medicare beneficiaries, in particular, have recognized the benefits of chiropractic services in managing musculoskeletal conditions. To ensure accurate reimbursement for chiropractic practitioners, understanding the Medicare billing guidelines is crucial. In this article, we will explore into the Medicare chiropractic billing guide, highlighting key points from the Centers for Medicare & Medicaid Services (CMS) to streamline the billing and coding process.

Medicare Chiropractic Billing Guide

1. Medicare Coverage for Chiropractic Services

The CMS provides a comprehensive resource for understanding the coverage of chiropractic services under Medicare. According to the CMS Medicare Coverage Database (MCD) article [1], chiropractic services are covered if they are reasonable and necessary for the diagnosis or treatment of a beneficiary’s illness or injury within the scope of chiropractic practice. It is important to note that routine maintenance or wellness care is not covered by Medicare.

2. Chiropractic Billing and Coding Guidelines

To ensure proper reimbursement for chiropractic services, it is essential to adhere to the CMS Billing and Coding Guidelines [2]. These guidelines offer valuable insights into the appropriate use of chiropractic procedure codes, documentation requirements, and the submission of claims.

3. Correct Use of Chiropractic Procedure Codes

Chiropractic care is typically identified using Current Procedural Terminology (CPT) codes. Chiropractors should select the most appropriate CPT code that represents the specific service provided. The CMS provides a list of covered chiropractic codes to facilitate accurate billing and coding. By utilizing the correct codes, chiropractic practitioners can avoid claim denials and delays in reimbursement.

4. Documentation Requirements

Accurate documentation is fundamental to successful Medicare billing for chiropractic services. The CMS emphasizes the need for thorough and detailed documentation, including the initial and subsequent evaluations, treatment plans, and progress notes. Proper documentation supports the medical necessity of chiropractic care and ensures compliance with Medicare guidelines.

5. Modifier Usage

Modifiers play a vital role in chiropractic billing by providing additional information about the services rendered. Common modifiers used in chiropractic care include “-AT” (acute treatment), “-GA” (waiver of liability statement issued as required by payer policy), and “-GX” (notice of liability issued, voluntary under payer policy). It is crucial to accurately append modifiers to claims to avoid potential payment issues.

6. Covered Evaluation and Management (E/M) Services

Chiropractors may bill for evaluation and management services in addition to the chiropractic manipulative treatment (CMT) codes. However, it is important to understand the specific requirements for E/M services, including the level of complexity, documentation requirements, and coding guidelines. Properly coding and documenting E/M services can significantly impact the reimbursement for chiropractic services.

7. Correct Coding Initiative (CCI) Edits

The Correct Coding Initiative (CCI) is a Medicare program that aims to prevent inappropriate payment for Medicare services. Chiropractors should be aware of the CCI edits, which may affect billing for certain code combinations. By reviewing the CCI edits, practitioners can ensure compliance and avoid potential claim denials.

8. Medicare Administrative Contractors (MACs)

Medicare chiropractic billing guidelines may vary slightly among different MAC jurisdictions. It is crucial for chiropractors to understand the specific guidelines applicable to their region. The MACs’ websites often provide local coverage determinations (LCDs), which contain additional information on coverage and billing requirements.

9. Compliance and Audits

To mitigate the risk of audits and ensure compliance with Medicare guidelines, chiropractors should establish robust compliance programs. Regular internal audits can help identify and rectify potential billing errors or documentation deficiencies. Staying up-to-date with CMS announcements and changes in Medicare policies is also critical.

10. Medicare Benefit Policy Manual (MBPM)

The MBPM, available on the CMS website, is an authoritative source that outlines Medicare’s policies and guidelines for various healthcare services, including chiropractic care. Chiropractors should consult the MBPM for detailed information on documentation requirements, covered services, and limitations.

11. Advanced Beneficiary Notice of Non-coverage (ABN)

In situations where chiropractic services may not meet Medicare’s coverage criteria, chiropractors should inform the patient in advance and have them sign an ABN. The ABN informs the patient of their financial responsibility if Medicare denies coverage for the service. Proper completion and documentation of the ABN are crucial to protect both the provider and the patient.

12. Limitations on Frequency and Duration

Medicare has limitations on the frequency and duration of chiropractic services. In general, Medicare covers up to 12 visits per calendar year when medically necessary. However, certain conditions may warrant additional visits if adequately justified and documented. Providers should ensure compliance with these limitations to avoid claim denials.

13. Medicare Secondary Payer (MSP)

In cases where Medicare is the secondary payer, such as when the patient has other insurance coverage, chiropractors must follow MSP guidelines. Billing processes and requirements may differ in these situations, and providers should verify the patient’s coverage and coordinate benefits accordingly.

Understanding the Medicare billing guidelines for chiropractic services is crucial for providers seeking proper reimbursement. By following the guidelines outlined by the CMS, chiropractors can navigate the complexities of Medicare billing and provide necessary care to Medicare beneficiaries. Regularly reviewing and staying updated on the CMS guidelines is essential to ensure compliance and minimize claim denials, ultimately benefiting both the provider and the patient.

Legion Healthcare Solutions is widely recognized as a reliable chiropractic billing company, offering comprehensive services to healthcare providers. With our expertise in navigating the intricate world of Medicare billing, Legion ensures accurate and timely reimbursement for chiropractic services. Our team of billing specialists stays updated on the latest CMS guidelines, including those specific to chiropractic care, guaranteeing compliance and minimizing claim denials. By entrusting their billing needs to Legion, chiropractors can focus on delivering high-quality care to their patients while having peace of mind knowing that their billing processes are handled efficiently and effectively.


  1. CMS Medicare Coverage Database
  2. CMS Billing and Coding Guidelines