Chiropractic Billing Compliance: Key Takeaways from CMS Article A56273

 

Chiropractic services are becoming acceptable as an essential, non-invasive approach for managing musculoskeletal conditions, especially among Medicare beneficiaries looking for the pharmaceutical and surgical options. But providing outstanding care is the sole need of the hour. In 2025, chiropractic providers, office managers, and medical billers face a rapidly changing billing environment, shaped by heightened Medicare scrutiny, evolving payer policies, and increasing claim denials.

Therefore, it is essential to keep updated on Medicare billing standards in order to remain in compliance. Centers for Medicare & Medicaid Services (CMS) Article A56273 is an essential guide for chiropractic billing compliance, providing essential information regarding documentation, eligibility of services, and coding guidelines.

This blog will offer major takeaways from CMS pertaining to chiropractic billing compliance.

Compliance of Chiropractic Billing & Coding Guidelines

The following guidelines outlines the key billing and coding practices chiropractors must follow when treating Medicare patients:

1. Coverage

Medicare only covers and pays for chiropractic services when it is medically necessary. These services are only intended for the active treatment of spinal subluxation, a partial spinal bone misalignment. These services have to be intended to correct a particular health condition and not for general health or routine care. Medicare does not cover acupuncture, massage therapy, or routine chiropractic checkups, even if these services are provided in a chiropractic clinic.

2. Basic Billing Rules

To receive payment, chiropractors must follow Medicare billing rules carefully. This includes choosing the correct codes, attaching any necessary modifiers, and submitting claims with accurate documentation. Claims need to be submitted using the Medicare CMS-1500 claim form, which is standard for outpatient healthcare providers.

3. Common CPT Codes Used

CPT codes must match the patient’s condition and treatment area for the claim to be considered valid. For instance, chiropractors should report spinal manipulation services using CPT codes 98940 to 98942, depending on how many spinal regions are treated. Code 98940 is used for 1–2 regions, 98941 for 3–4 regions, and 98942 for all 5 regions. Chiropractors are not allowed to bill Medicare for extra services like x-rays, massage, or physical therapy unless performed by a Medicare-approved provider type.

4. Required Chiropractic Documentation

Proper records are crucial for Medicare to approve payment of the chiropractic services. A complete documentation of the initial exam is required by chiropractors. It must include the patient symptoms, history, and physical examination. They must also record the diagnosis of subluxation, which can be based on physical examination or x-rays taken earlier. There should be adequate clinical documentation for every encounter that should describe the patient’s progression, mention positive changes or improvement..

5. Use of Modifiers

The CPT codes are followed by modifiers that are referred to as the codes which further explain the service provided. The “AT” modifier used in chiropractic care shows that treatment is for acute problems (rather than maintenance issues). Medicare payment is generally dependent on the presence of such modifiers. Other important modifiers are “GA” in the event the patient has agreed to waive the coverage for a service which Medicare covers or “GX” for services given as a voluntary basis and not usually covered. Claims without the right modifier may be denied.

6. Billing for Exams (E/M Services)

If a chiropractor performs a full evaluation that is separate from the spinal adjustment, it may be billed as an Evaluation and Management (E/M) service using codes like 99202–99215. However, this must be clearly different from the manipulation service and documented accordingly. When billing both on the same day, chiropractors should add the “-25” modifier to the E/M code to show that the service was distinct.

7. Check the CCI Edits

The Correct Coding Initiative (CCI) is a Medicare program that prevents payment for code combinations that shouldn’t be billed together. If adhered to these rules, chiropractors can ensure that their claims do not get denied for overlapping services under Medicare’s review. Reviewing the latest CCI edits helps providers to make sure that their claims follow the national standards.

8. Local Medicare Rules May Vary (MACs)

Medicare rules may vary slightly depending on where the chiropractor is based. Different Medicare Administrative Contractors (MACs) manage claims in different regions. Chiropractors should refer to their local Local Coverage Determination (LCD) to see precisely which services are payable and under what circumstances. Each MAC posts these LCDs on their websites.

9. Stay Compliant and Prepare for Audits

To avoid repayments, denials, or audits, it is important to maintain compliance with Medicare rules. Chiropractors should perform internal audits regularly to review their billing and documentation practices. This helps catch any errors early and stay within Medicare’s expectations. Having a written compliance plan in the office and outsourcing offshore medical billing and coding services in India also supports good billing practices.

10. Refer to the Medicare Benefit Policy Manual (MBPM)

For detailed and official guidance, chiropractors should consult the Medicare Benefit Policy Manual, particularly Chapter 15, Section 240, which covers chiropractic care. This manual explains what documentation is required, which services are covered, and the exact conditions under which care is considered medically necessary. It is available for free on the CMS website and should be checked regularly for updates.

11. Give an ABN When Needed

If the chiropractor believes Medicare may not cover a certain service, the patient should be informed ahead of time and asked to sign an Advance Beneficiary Notice (ABN). This form describes the possible denial and transfers the financial burden to the patient. A signed copy of the ABN should be retained within the patient’s file. Giving the ABN after treatment or failing to give it at all may leave the provider responsible for the cost.

12. Know the Visit Limits

Medicare limits how many chiropractic visits it will cover per year. Typically, up to 12 visits annually are allowed if the treatment is medically necessary. Additional visits can be approved if the chiropractor provides strong documentation showing improvement or a valid reason for extended care. Records should clearly show measurable outcomes like pain reduction, increased mobility, or return to work activities.

13. When Medicare is the Secondary Payer

Sometimes, Medicare is not the patient’s main insurance. If the patient has another health plan, that plan usually pays first. Chiropractors must follow the Medicare Secondary Payer (MSP) rules in these cases. It is important to verify the patient’s coverage, submit the claim to the primary payer first, and then send any remaining balance to Medicare. Claims sent to Medicare without checking MSP status may be rejected.

Conclusion

Chiropractic billing can be challenging, but it can’t stop you from focusing on what you love, i.e., helping patients feel better. With proper knowledge of CMS guidelines (particularly the critical points outlined in Article A56273), you can take proactive steps toward compliance, reduce claim denials, and secure the reimbursements your practice deserves. In fact, every effort you make right from mastering documentation and accurate coding to using technology and outsourcing when needed, strengthens your practice’s financial health.

It is also important to remember that consistent education, backed by trusted sources like the American Chiropractic Association (ACA) and CMS, remains essential in 2025’s evolving regulatory environment. If you are still feeling confused regarding such rules, outsourcing medical billing and coding services providers in India like Info Hub Consultancy Services is your trusted billing partner.

FAQs

1. Can chiropractors bill for X-rays under Medicare?
Medicare does not reimburse chiropractors for X-rays even if used for treatment planning.

2. What is the biggest reason chiropractic claims get denied in 2025?
The lack of documented subluxation with a treatment plan is the top reason for denial.

3. Are maintenance chiropractic visits covered by Medicare?
Maintenance therapy is not considered medically necessary and is not covered.

4. Can chiropractors bill for telehealth services?
Chiropractors can’t bill for telehealth services as face to face interaction is a must.