Medicare Guidelines for Chiropractic Billing and Coding

First, for a quick introduction for those who may not know what chiropractors do? According to WebMD, Chiropractic is a healthcare profession that cares for a patient’s neuromusculoskeletal system — the bones, nerves, muscles, tendons, and ligaments. A chiropractor helps manage back and neck pain through the use of spinal adjustments to maintain good alignment.

Chiropractic is focused on the body’s ability to self-heal and includes other treatments like nutrition and exercise.

By improving the neuromusculoskeletal system’s ability to perform, chiropractors believe the benefits of spinal adjustment and realigning joints improve the functioning of other systems throughout the body.

What Does a Chiropractor Do?

Chiropractors conduct an examination of a patient, looking at the spine’s position and muscle reflexes. They also perform tests and may take x -rays to diagnose the patient’s condition, then come up with a treatment plan and monitor progress.

Chiropractors do not prescribe pain medication. Instead, they rely on and assist the body’s ability to heal itself. A chiropractor’s primary therapy is spinal manipulation where they use hands or instruments to apply force to a joint in the spine, moving the joint in a specific direction for better alignment.

In addition to spinal manipulation, chiropractors may include other treatments such as:

• Relaxation

• Stimulation

• Hot and cold treatment

• Exercise

• Diet and weight loss counseling

Medicare Guidelines for Billing and Coding for Chiropractic Services

Coverage of Chiropractic services is a limited benefit. The coverage is limited to manual manipulation for the treatment of subluxation. “Subluxation” is a term used by Chiropractors to describe a spinal vertebra that is out of position in comparison to the other vertebrae.

Claims submitted for Chiropractic Manipulative Treatment (CMT) CPT codes 98940, 98941, or 98942, (found in Group 1 codes under CPT/HCPCS Codes) must contain an AT modifier or they will be considered not medically necessary.

Payment is to the billing Chiropractor and is based on the physician fee schedule. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.

Coding Guidelines

1. The precise level of the subluxation must be specified on the claim and must be listed as the primary diagnosis. The neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis.

2. All claims for chiropractic services must include the following information:
   Date of the initiation of the course of treatment.
   Symptom/condition/Secondary diagnosis code(s)
   Subluxation(s)/Primary diagnosis code(s)
   Date of Service
   Place of Service
   Procedure Code
   Failure to report these items will result in claim denial or delay.

3. Note: The date of last x-ray is no longer required. Any date placed in item 19 is considered the date of the last x-ray. It is recommended that providers do not place any date in item 19 of the CMS-1500 claim form.

4. Limitation of Liability rules apply: The purpose of the Limitation of Liability provision is to protect the beneficiary from liability in denial cases under certain conditions when services rendered are found to be not reasonable and medically unnecessary.

5. If the provider uses the AT Modifier and believes service is likely to be denied by Medicare as not being medically necessary, the beneficiary must sign an Advance Beneficiary Notification (ABN) and the GA modifier must be used.

6. Physician signature for progress notes and reports (handwritten, electronic). Initials if signed over a typed or printed name or accompanied by a signature log or attestation statement.

Non-Covered Services:
All services other than manual manipulation of the spine for treatment of subluxation of the spine are excluded when ordered or performed by a Doctor of Chiropractic. Chiropractors are not required to bill these to Medicare. Chiropractic offices may want to submit charges to Medicare to obtain a denial necessary for submitting to a secondary insurance carrier. The following are examples (not an all-inclusive list) of services that, when performed by a Chiropractor, are excluded from Medicare coverage:
- Laboratory tests
- X-rays
- Office Visits (history and physical)
- Physiotherapy
- Traction
- Supplies
- Injections
- Drugs
- Diagnostic studies including EKGs
- Orthopedic devices
- Nutritional supplements and counseling

Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage, and abdomen.

CPT/HCPCS Codes

Group 1

98940 — CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 1–2 REGIONS

98941 — CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 3–4 REGIONS

98942 — CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 5 REGIONS

Group 2

98943 — CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); EXTRASPINAL, 1 OR MORE REGIONS

ICD-10-CM Codes that Support Medical Necessity

There are 4 Groups and each include, 6, 47, 192, and 66 codes, totalling 311 for ICD-10-CM codes to support medical necessity for your Chiropractic services. For further details on these codes and their proper use, Trucare Billing is happy to offer their services.

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