Chiropractic billing hinges on one Medicare-specific rule above all others: every active-treatment claim for spinal manipulation must carry the AT modifier, and the medical record must document subluxation with PART criteria—without it, claims are automatically denied as maintenance care. VeriMedix provides the coding discipline and denial management chiropractic practices need to sustain revenue under tight Medicare coverage rules.
Medicare covers chiropractic services for one purpose only: manual manipulation of the spine for the treatment of a spinal subluxation. All other chiropractic services—physiotherapy modalities, massage, acupuncture, extremity adjustments (98943), X-ray interpretation, nutritional counseling, and wellness care—are excluded from Medicare coverage. Chiropractors are not required to bill non-covered services to Medicare, but may do so to obtain a denial letter needed to submit to secondary insurance. The spinal manipulation codes 98940 (1–2 spinal regions), 98941 (3–4 regions), and 98942 (5 regions) are the only Medicare-covered chiropractic procedure codes, and they must always be accompanied by the AT modifier for active treatment. Claims submitted without AT are automatically treated as maintenance therapy and denied.
Subluxation documentation using the PART system (Pain, Asymmetry, Range of motion, Tissue tone) is the Medicare documentation standard for chiropractic services. The primary diagnosis must be the subluxation, coded at the specific spinal level (e.g., M99.01 for cervical, M99.03 for thoracic, M99.04 for lumbar). The secondary diagnosis should reflect the neuromusculoskeletal condition for which treatment is being provided (e.g., M54.5 for low back pain). On the CMS-1500 claim form, the date of first treatment in the course of care is required. The level of subluxation must be specified in both the claim and the medical record. Overuse of general codes like M54.5 without specific subluxation documentation is a significant audit risk.
The distinction between active treatment and maintenance care is central to Medicare compliance. Active treatment (coded with AT modifier) is care expected to improve the patient's condition—reduce pain, improve function, restore mobility. When maximum therapeutic benefit has been achieved and further improvement is not expected, continued care becomes maintenance therapy. Maintenance therapy is not covered by Medicare and must not be billed with the AT modifier. If a provider believes a service is likely to be denied as not medically necessary but provides it anyway (e.g., continuing care for a patient who has plateaued), the patient must sign an ABN and the claim must be submitted with modifier GA. Failure to issue an ABN exposes the provider to liability for the billed amount.
Below are commonly billed codes our certified coders manage for chiropractic practices. Always confirm payer-specific coverage and current code values.
| Code | Description | Billing note |
|---|---|---|
98940 | Chiropractic manipulative treatment (CMT); spinal, 1–2 regions | Requires AT modifier for Medicare active treatment; most commonly used CMT code for localized treatment |
98941 | Chiropractic manipulative treatment (CMT); spinal, 3–4 regions | Document all 3–4 specific regions treated in the clinical note; do not upcode if fewer than 3 regions were treated |
98942 | Chiropractic manipulative treatment (CMT); spinal, 5 regions | Highest-level spinal CMT; elevated audit risk when used repeatedly; must document all 5 regions treated with PART findings |
98943 | Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions | Not covered by Medicare; may be covered by commercial payers; use for shoulder, knee, foot, or other extraspinal adjustments |
97140 | Manual therapy techniques; each 15 minutes | Covered by some commercial payers when performed by a chiropractor; requires separate documentation from CMT; not covered by Medicare when ordered/performed by DC |
99203 | New patient office visit; moderate MDM or 30–44 minutes | E/M services ordered by a DC are excluded from Medicare coverage; may be billed to commercial payers with modifier 25 when a separately identifiable E/M is performed |
M99.01 | ICD-10: Segmental and somatic dysfunction; head region (subluxation diagnosis) | Level-specific subluxation must be the primary diagnosis on all Medicare chiropractic claims |
M99.03 | ICD-10: Segmental and somatic dysfunction; thoracic region | Must match the specific spinal level treated per the PART documentation in the note |
M99.04 | ICD-10: Segmental and somatic dysfunction; lumbar region | Most common subluxation diagnosis for low back complaints; link to secondary condition code (e.g., M54.5) |
Our standard operating procedures for chiropractic revenue cycle management — the step-by-step workflow we follow on every claim:
These are the issues we see most often in chiropractic billing — and exactly how we resolve them:
Submitting 98940–98942 to Medicare without the AT modifier results in automatic denial as maintenance care. This is the single most common chiropractic billing error. Fix: implement a hard billing rule that prevents submission of any CMT code to Medicare without the AT modifier; add a scrubbing checkpoint at claim generation.
Medicare requires the subluxation diagnosis (M99.01–M99.07, specific spinal region) as the primary diagnosis on chiropractic claims. Using a symptom code (e.g., M54.5 back pain) as primary and omitting the subluxation code violates claim requirements and triggers denial. Fix: build a billing system rule that flags any chiropractic Medicare claim where the primary diagnosis is not from the M99 subluxation code range.
Billing 98941 (3–4 regions) when the chart documents only a cervical and lumbar adjustment (2 regions) is overcoding subject to recoupment and audit. Fix: require documentation of each specific spinal region treated in the SOAP note; implement coder review before billing 98942 to confirm all 5 regions are documented.
When a patient has reached maximum therapeutic benefit and further improvement is not expected, continued care is maintenance—not active treatment. Using AT modifier on maintenance visits misrepresents the nature of care and constitutes Medicare fraud risk. Fix: establish a clinical protocol for evaluating and documenting when a patient transitions from active treatment to maintenance; require providers to issue an ABN and switch to GA modifier at that transition.
All services ordered or performed by a Doctor of Chiropractic are excluded from Medicare coverage except spinal manipulation for subluxation. Billing E/M codes to Medicare for a chiropractic patient results in denial. Fix: suppress E/M code billing on Medicare chiropractic claims; route E/M codes only to commercial payer claims where coverage is verified and a separately identifiable visit is documented with modifier 25.
Verimedix works inside the systems chiropractic practices already use, including:
The five spinal regions recognized for chiropractic CMT coding are: (1) cervical, (2) thoracic, (3) lumbar, (4) sacral, and (5) pelvic. The number of regions treated—not the number of individual vertebrae adjusted—determines the CMT code level. Treating one cervical and one lumbar subluxation = 2 regions = 98940. Treating cervical, thoracic, and lumbar = 3 regions = 98941. All five regions = 98942.
Yes and no. The taking and interpretation of X-rays ordered by a chiropractor is technically a separate radiology service under a different provider specialty code. However, because all services ordered or performed by a DC are excluded from Medicare coverage (except spinal CMT), X-rays ordered solely by the chiropractor are non-covered. If an independent radiologist interprets the images, that professional component may be separately billable. The most practical approach is to refer the patient for imaging to a qualified radiologist billing under their own NPI.
No. CPT 98943 (extraspinal chiropractic manipulative treatment—e.g., shoulder, knee, hip, foot adjustments) is not covered by Medicare. Chiropractors may still perform and bill these services to commercial payers or directly to patients where coverage exists. If billing 98943 to Medicare to obtain a denial for secondary insurance purposes, append modifier GY (item or service statutorily excluded) to avoid generating a claim that could be misinterpreted as an active-treatment billing attempt.
While Medicare does not specify a mandatory re-certification interval for chiropractic, CMS expects providers to periodically assess whether the patient continues to meet active treatment criteria—that is, whether there is measurable functional improvement or reasonable expectation of improvement. Best practice is to re-evaluate every 30 days or every 12–15 visits, whichever is sooner, and document measurable progress. Inability to demonstrate progress over time is the basis for a transition to maintenance care designation.
PART is the Medicare-accepted documentation framework for chiropractic subluxation: Pain (subjective complaint—location, type, VAS score), Asymmetry (objective postural or spinal misalignment finding), Range of Motion (objective measurement of ROM at the affected region), and Tissue Tone (objective finding of muscle guarding, spasm, edema, or abnormal texture). Each element must be documented at each visit to support the subluxation diagnosis and justify active treatment coding. Incomplete PART documentation is a leading trigger for Medicare post-payment review and recoupment.
Only if there is a licensed physical therapist on staff who provides PT services under their own NPI and licensure. Chiropractic services and physical therapy services are billed under different provider types. A chiropractor billing PT codes under their DC license would be fraudulent unless they hold dual licensure. When a PT-licensed provider renders PT services at a chiropractic practice, those services are billed under the PT's NPI and the applicable PT CPT codes (97110, 97140, etc.) with the GP modifier for Medicare.
Commercial payers often cover a broader range of chiropractic services than Medicare: extraspinal manipulation (98943), modalities, and sometimes E/M services may be covered depending on the plan. Visit limits per year are common (e.g., 20–30 visits per benefit year). Some Blue Cross Blue Shield plans allow CMT plus an E/M with modifier 25 when a separately identifiable evaluation is documented. Authorization requirements and pre-certification processes vary widely. Always verify each commercial payer's specific chiropractic benefit before assuming Medicare rules apply.
Verimedix handles the entire chiropractic revenue cycle — coding, submission, denials, and A/R — so your team can focus on patients.