How to Bill Medicare for Chiropractic Services in the US

For doctors of chiropractic (DCs) in America, learning how to bill Medicare for chiropractic services is something of an art (as well as being a necessity for many!) Medicare patients form an important part of many chiropractic practices but billing correctly takes a bit of learning. You have to get your coding and documentation right; and that’s before you even get into the important details like establishing the medical necessity of any treatments that you provide.

Looking for help on how to bill Australian Medicare for chiropractic services? We’ve got you covered.

If you have a US-based practice and have been looking for a guide to billing Medicare correctly, this is it. It’s a step-by-step process that will help you create a billing framework for your own practice. We’ve got the codes you can bill under, what documentation you need, and how to get the details of the claim right. Let’s dive right in, starting with Medicare codes:

1. US Medicare Codes

We’ll start with the good news: Medicare does cover some chiropractic treatments but, unfortunately, it’s quite a shortlist. There are only three CPT (Current Procedural Terminology) codes that can be claimed by chiropractic providers.

In order to be approved for any of these three, you will need to carefully demonstrate a subluxation diagnosis and the need for manual manipulation of the spine. This means that before you even start with the treatment, you’ll need to establish that:

Your treatment is a medical necessity;
Your diagnosis meets the patient’s needs.

Failure to adhere to these two requirements will lead to your claim being denied, and may even be considered attempted fraud.

Finding and using the right CPT code is just the first hurdle. If you can’t establish that manual manipulation is necessary (through an assessment of the client’s symptoms, history, and a physical examination), your claim is likely to be rejected. So, let’s press on and do a deep dive into Medicare’s claim requirements.

2. US Medicare Claim Requirements

Initial Consultation

Medicare requires that you furnish all the information relevant to your patient’s condition during the initial consultation. This should include the client’s:

Primary complaint

Carefully detail the issue that the patient has and the symptoms that they are experiencing that led them to seek treatment.

Medical history and family background

These may be related to the case if there has been an auto accident or a hereditary bone condition.

Presentation of the condition

Describe your patient’s illness, including important details such as when and where the trauma originated, what the symptoms are (location, duration, frequency, intensity, and onset), and any information about what aggravates or relieves the symptoms. Also, be sure to include any previous treatments and interventions, medications, and secondary complaints.

Physical examination

If a subluxation is identified during the physical exam, Medicare requires that the patient’s condition satisfies at least two additional criteria that need to be properly documented. The necessary criteria are:

A: An asymmetry or misalignment that you have observed through imaging and static palpation.
R: An abnormal range of motion – this is diagnosed through measurement or observation in a segment or section.
T: The tissue tone – document any texture or temperature abnormality of the body’s soft tissues.
P: Any pain or tenderness – as the provider, you need to be able to specifically and in detail, describe the intensity, type, and location of the pain.

Diagnosis

Medicare requires that subluxation be the primary diagnosis in order for it to be covered. This means that you will need to include specific about the bones that require treatment as well as specifics about the area of the spine involved.

Treatment plan

When it comes to detailing your treatment plan for the client, the more information you include, the better. A quick checklist of what to cover for the initial session includes:

An estimation of the number and frequency of sessions that the patient needs;
A list of the specific goals of your treatment for them;
Objective, measurable benchmarks that you can use to determine whether the treatment is successful;
The date of the first treatment appointment;
A full medical record.

Follow-Up Appointments

For any subsequent visits you should include:

A review of the patient’s history noting the primary complaint and any changes to their condition. This should include a review of their current symptoms.
A follow-up physical exam to examine any changes in the patient. This will help you determine whether the treatment is yielding results.
Follow-up treatment documentation – if you provide additional treatment, it needs to be documented in full.

For more information on medical record documentation requirements for initial and subsequent visits, visit the Centers for Medicare & Medicaid Services (CMS).

3. US Medicare Billing

Medicare’s specific billing requirements limit covered treatment to manual manipulation of the spine to correct a subluxation. In other words, DC needs to use their hands or manual devices (handheld devices that control the thrust force manually). There is no additional payment for the use of a device.

Other requirements to keep in mind when investigating how to bill Medicare for chiropractic services include:

Direct billing, if you have performed a spinal manipulation on a Medicare client, Medicare should be billed directly for the service, whether the treatment was for an active acute or chronic condition or for maintenance care.
No cash discounts, federal anti-kickback laws prohibit discounts for Medicare beneficiaries.
Medicare limits, there are no caps on chiropractic care provided that your documentation is thorough and that you have met the criteria.
Limiting charges, chiropractors who do not accept assignment can only charge up to 115% of the approved payment amount. This amount is referred to as a limiting charge.
Non-covered services, any professional services rendered by a chiropractor (aside from spinal manipulation to correct a subluxation) are not covered by Medicare.

4. FAQ About How to Bill Medicare for Chiropractic Services in the US

To round off, let’s have a look at the most frequently asked questions around Medicare billing for chiropractors:

Does Medicare pay for chiropractic service?

Yes, but you have to bill under the correct codes and make sure you’ve fulfilled all the documentation and claim requirements. You are also required to establish that your treatments were medically necessary.

How much does Medicare pay for a chiropractic appointment?

Keep in mind that Medicare only covers necessary chiropractic services. As per the CMS website, under Medicare Part B, the insurance covers 80% of the cost of “manipulation of the spine if medically necessary to correct a subluxation.” Medicare will only cover spinal manipulation; there is no allowance for other treatments such as x-rays or massage therapy.

What codes can a chiropractor bill?

The three codes are:

CPT Code 98940 – this is for chiropractic manipulative treatment (CMT) of the spine in 1-2 regions;
CPT Code 98941 – this is for chiropractic manipulative treatment (CMT) of the spine in 3-4 regions;
CPT Code 98942 – this is for chiropractic manipulative treatment (CMT) of the spinal in 5 regions.

How many chiropractic visits will Medicare cover?

Medicare will cover up to a total of twelve sessions over the course of ninety days. If there is evidence of improvement in the patient’s condition, eight additional sessions can be added.

Do I need X-ray proof of a patient’s subluxation?

No, the CMS eliminated the need for X-rays in January 2000. Previously, doctors of chiropractic were required to refer patients to a radiologist for X-rays to demonstrate the subluxation. However, an X-ray can still be used, provided that it is within 12 months before or three months following the commencement of treatment. In some cases, such as a scoliosis diagnosis, older X-rays may be submitted as proof of an ongoing, permanent condition. CT and MRI scans are also considered acceptable evidence if they demonstrate a subluxation of the client’s spine.

Billing accurately under the available CPT codes will dramatically improve your approval rates. Best practice dictates that you stick to the three approved codes, then focus on including the right wording (and a lot of detail) in your documentation. The right chiropractic software can make managing all of this much easier. If you can get these two steps right you’ll have successfully mastered the basics of how to bill US Medicare for chiropractic services in your practice.

If you know of a US-based chiropractic practice who wants to start accepting Medicare patients but doesn’t know where to start (or has been burned in the past), please pass this on. Once you get the hang of their procedures and requirements, you’ll quickly learn how to bill accurately and get those claims approved!