Understanding Chiropractic Billing Services for Medicare Beneficiaries

Understanding Chiropractic Billing Services for Medicare Beneficiaries

With the evolving healthcare landscape, chiropractic care has gained recognition as a valuable treatment option. Medicare beneficiaries have also recognized its benefits. These services are valued for their non-invasive approach to treating musculoskeletal conditions. Chiropractic practices depend on chiropractic billing services for the insurance claim processing. These services are typically outsourced to third-party billing companies like P3 Care. However, chiropractic billing services must understand Medicare billing guidelines for accurate reimbursement.

In this article, we will delve into the Medicare chiropractic billing guide. In this guide, we will be focusing on key points outlined by CMS. By familiarizing yourself with these guidelines, you can streamline the chiropractic billing and coding process.

Chiropractic Care and Medicare Billing: A Comprehensive Guide

Medicare Coverage Offered for Chiropractic Services

CMS has provided clear instructions for the chiropractic services. No doubt, Medicare covers chiropractic services, however, there are specific criteria to fulfill. According to the coverage criteria, Medicare includes chiropractic services only if:

  • First, they are reasonable.
  • Second, they are vital for the treatment or diagnosis of an illness or injury.
  • Third, the care services fall under the scope of chiropractic practice.

Thus, chiropractic billing services must keep a strict check on the aforementioned conditions. One thing that must be kept in mind is routine maintenance or wellness care. Medicare does not provide coverage for such cases. For detailed information on chiropractic service coverage, you can refer to the CMS Medicare Coverage Database (MCD).

Chiropractic Billing and Coding Guidelines

Adhering to the CMS Billing and Coding Guidelines is equally important. It ensures proper reimbursement for chiropractic services. These guidelines provide insights into the following:

  • Appropriate use of chiropractic procedure codes
  • Comprehensive documentation requirements
  • claims submission guide

Correct Use of Procedure Codes in Chiropractic Billing

Chiropractors should select the most suitable CPT code that accurately represents the service provided. To facilitate accurate billing and coding, the CMS offers a list of covered chiropractic codes. By doing so, chiropractic billing services can avoid claim denials and delays in reimbursement.

Use of Chiropractic Modifiers

Modifiers provide additional information about the chiropractic services rendered. Accurately appending modifiers to claims assists in avoiding potential payment issues.

Common modifiers used in chiropractic care include the following:

  1. “-AT” (acute treatment)
  2. “-GA” (waiver of liability statement as required by payer policy)
  3. “”-GX” (voluntarily provided notice of obligation under payer policy)

Coverage of Evaluation and Management (E/M) Services

Chiropractors have the option to bill for E/M services along with chiropractic manipulative treatment (CMT) codes. However, we can’t neglect the importance of understanding the specific requirements for E/M services. It may include complexity levels, documentation requirements, and coding guidelines. Properly coding and documenting E/M services can significantly impact reimbursement for chiropractic billing services.

Correct Coding Initiative (CCI) Edits

CCI is a Medicare program designed to prevent inappropriate payments for Medicare services. Chiropractors should be aware of the CCI edits. It may affect billing for certain combinations of codes. By reviewing the CCI edits, practitioners can ensure compliance and avoid potential claim denials.

Documentation for Medicare Billing Success

The secret to successful Medicare chiropractic billing is accurate documentation. CMS places a high value on comprehensive record-keeping. It must include thorough initial and follow-up assessments, treatment plans, and progress reports. Chiropractors can establish the medical necessity of their service by following these documentation standards rigorously.

Medicare Benefit Policy Manual (MBPM)

The Medicare Benefit Policy Manual (MBPM) is a helpful resource available on the CMS website. It contains important information about Medicare’s policies and guidelines for different healthcare services, including chiropractic care. If you’re a chiropractor, it’s a good idea to check the MBPM for detailed information. It will educate you about topics like:

  • What documentation do you need?
  • Which services are covered?
  • Are there any limitations you should be aware of?

Medicare Administrative Contractors (MACs)

The guidelines for chiropractic billing and coding services under Medicare can differ slightly. It depends on the jurisdiction of the Medicare Administrative Contractors (MACs). To ensure accurate chiropractic billing, it’s important to be familiar with the region-specific guidelines. The MACs’ websites are a valuable resource as they often provide local coverage determinations (LCDs). These LCDs contain additional information regarding coverage and requirements for medical billing services. Thus, you can ensure compliance with Medicare guidelines by doing so.

Advanced Beneficiary Notice of Non-Coverage (ABN)

Sometimes chiropractic services may not meet the coverage criteria set by Medicare. In that case, chiropractors need to communicate this to the patient in advance. Thus, they have to obtain their signature on an Advanced Beneficiary Notice of Non-Coverage (ABN). The purpose of the ABN is to inform the patient about their financial responsibility. It is essential to complete and document the ABN correctly to ensure the protection of both the healthcare provider and the patient.

Frequency and Duration Limits by Medicare

Medicare imposes specific limitations on how often and for how long chiropractic services are covered. Typically, Medicare covers up to 12 visits per calendar year if they are deemed medically necessary. However, there are instances where additional visits may be justified and allowed if properly justified and documented. Healthcare providers must adhere to these limitations to prevent claim denials and ensure compliance with Medicare guidelines.


Thus, all chiropractors must have a solid grasp of the Medicare guidelines for billing services. It will ensure appropriate reimbursement. Adhering to the guidelines established by CMS allows chiropractors to navigate the intricacies of Medicare billing. As a result, they deliver essential care to Medicare beneficiaries and perform chiropractic billing services effectively. It is vital for chiropractors to regularly review and stay informed about the CMS guidelines to maintain compliance. It reduces the risk of claim denials.

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