Chiropractic Coverage for Medicare
What is Covered?
The only chiropractic service covered by Medicare is manual manipulation of the spine. No
other diagnostic or therapeutic services furnished by a chiropractor, or furnished on his/her
order, are covered. The treatment must be medically necessary.
Beneficiary must have a significant health problem in the form of a neuromusculoskeletal
condition necessitating treatment.
98940 - Spinal, 1-2 regions
98941 - Spinal, 3-4 regions
98942 - Spinal, 5 regions
Note: these are the only CPT codes and Spinal areas that Medicare will cover.
ICD-9 Codes for Chiropractic Services
739.0 - Nonallopathic lesions of head region not elsewhere classified
739.1 - Nonallopathic lesions of cervical region not elsewhere classified
739.2 - Nonallopathic lesions of thoracic region not elsewhere classified
739.3 - Nonallopathic lesions of lumbar region not elsewhere classified
739.4 - Nonallopathic lesions of sacral region not elsewhere classified
739.5 - Nonallopathic lesions of pelvic region not elsewhere classified
Note: Check your local Medicare Carrier for specific subluxation codes some may utilize the 837 series. The subluxation codes need to be placed in the first and third position in box 21 on the CMS 1500 form. Other diagnosis codes and subluxation codes for example 723.1, 729.1 etc.., are to be placed in the first and third position. Additional codes which are common can be placed in box 19 on the 1500 form.
HCPCS Modifier AT
When a chiropractor provides active/corrective treatment, for either acute or chronic
subluxation, the service must be submitted with HCPCS modifier AT. If the service qualifies as "maintenance therapy," it must be submitted without HCPCS modifier AT and the service will be denied.
Frequency of Chiropractic Visits
There is no set limit on the number of treatments. For acute subluxation problems, the patient's
condition will determine the frequency. In the first few days, treatment may be quite frequent but
will decrease over time or as the patient's condition improves. "Chronic" subluxation implies that
the condition has existed for a longer period of time, so the involved joints may have set. "
Chronic conditions may require a longer treatment time, but not at a higher frequency. Medicare
will only reimburse one treatment per day unless documentation supporting the medical necessity for
additional services is submitted with each claim.
Note: This is not for maintenance therapy.
There is no requirement for chiropractors to obtain x-rays prior to treatment. X-rays that are ordered, taken, or interpreted by chiropractors can be used for claims processing purposes, but they are not covered by
v Manipulation is not covered when:
v An absolute contraindication exists.
v Mechanical or electrical equipment is used.
v The x-ray or diagnostic test does not support one of the primary covered diagnoses.
v The claim lacks one of the primary covered diagnoses.
v Medicare never covers CPT code 98943 (extraspinal manipulation).
Note: A contradiction is when a manipulation (dynamic thrust) adds a significant risk of injury to the patient.
CMS defines maintenance therapy as "a treatment plan that seeks to prevent disease,
promote health, and prolong and enhance the quality of life; or therapy that is performed to
maintain or prevent deterioration of a chronic condition." Continued repetitive treatments without
an achievable, clearly-defined goal are considered maintenance therapy. Medicare does not
cover maintenance therapy.
v Non-covered services include:
v Physical Therapy
v Treatment for diagnoses which are not considered to be medically necessary
v Office visits
v Manipulation of body parts other than the spine
v Laboratory tests
v EKGs or other diagnostic tests
v Nutritional supplements/counseling
v Services ordered by chiropractors
Common Claim Denials
Medically Unnecessary Services
v Non-acute conditions that do not meet medical necessity
v Acute conditions that do not show reasonable expectation of recovery or improvement of function
Services Coded Incorrectly
v Upcoding: Billing for preventive or maintenance care on areas in excess of the acute condition
regions under active treatment
v Failure to use the GZ modifier, if advance notice of non-coverage was not provided to the
Advance Beneficiary Notice
Use ABN Form CMS-R-131 for services for which Medicare is likely to deny payment due to frequency or medical necessity. http://www.cms.hhs.gov/BNI/02_ABN.asp#TopOfPage
Examples of when you should ask the patient to sign an ABN:
v Treatment is given for a diagnosis not related to subluxation
v Treatment is given for maintenance therapy
v If patient refuses to sign, notate refusal on form, have two staff members sign and date form, submit claim with HCPCS modifier GA.
Financial Responsibility Modifiers:
HCPCS Modifier Description Financial Responsibility
v GA ABN on file Patient
v GZ Service expected to be denied as not
reasonable and necessary Contractual Obligation
v GY Statutorily excluded or not a Medicare
HCPCS Modifier AT
v When a chiropractor provides active/corrective treatment, for either acute or chronic
subluxation, the service must be submitted with HCPCS modifier AT.
v If the service qualifies as "maintenance therapy," it must be submitted without HCPCS
modifier AT and the service will be denied.
v Use of HCPCS modifier AT does not automatically mean the service meets the "medical
v The patient's medical record must support the use of this modifier.
AT Modifier Use
v AT Patient under active or corrective treatment
v AT + GA D.C. has patient under active treatment but feels Medicare may deem as
not medically necessary
v 100-01, Chapter 5, section 70.6 (chiropractor definition)
v 100-02, Chapter 15, section 30.5 (coverage)
v 100-02, Chapter 15, section 240 (necessity for treatment)
v 100-04, Chapter 12, section 220 (documentation requirements)