Chiropractic medical billing is one of the most nuanced areas of healthcare financial management, requiring precise documentation, proper coding, and a strong understanding of payer-specific policies. Chiropractors face more scrutiny than many other specialties because services are often classified as maintenance care or limited by insurance coverage rules. This guide provides a complete, high-authority breakdown of how chiropractic billing works, why it is complex, and how to manage it successfully.
What Is Chiropractic Medical Billing?
Chiropractic medical billing is the process of coding, documenting, and submitting claims for chiropractic services to payers such as Medicare, Medicaid, and private insurers. It includes verifying patient benefits, using the correct ICD-10 and CPT codes, proving medical necessity, and ensuring claims meet payer-specific guidelines.
What makes chiropractic billing unique is that coverage is often limited, frequency is strictly monitored, and documentation is heavily scrutinized. Small errors such as incorrect coding or insufficient SOAP notes can lead to denials.
Accurate chiropractic medical billing matters because correct documentation supports medical necessity, reduces denials, and directly impacts reimbursement. Chiropractors also face challenges with insurance acceptance because many payers classify certain services as non-covered or limit them based on clinical findings.
Comprehensive Overview of Chiropractic Medical Billing
How Chiropractic Medical Billing Works
Chiropractic billing follows the standard medical billing workflow but with added layers of payer scrutiny. Chiropractors must document medical necessity for every adjustment and therapy, tie diagnoses to treatment, and ensure compliance with Medicare’s strict coverage rules.
Key Components of the Billing Cycle for Chiropractors
Patient intake: Initial exam, diagnosis, medical necessity establishment.
Verification: Determine coverage limits, exclusions, and frequency caps.
Coding: Apply correct CPT and ICD-10 codes based on regions treated and patient condition.
Documentation: SOAP notes, treatment plans, progress notes.
Claims submission: Electronic claims through clearinghouses.
Follow-up: Track claim status, correct errors early.
Denials management: Appeal rejected claims with supporting documentation.
Why Chiropractic Medical Billing Is More Complex than Other Specialties
Limited covered services: Many adjustments or modalities are classified as maintenance care.
Medical necessity scrutiny: Every visit must justify active care.
Frequency limitations: Insurers cap the number of covered visits.
Payer-specific restrictions: Medicare chiropractic coverage differs significantly from private payers.
Chiropractic Medical Billing Codes and Documentation Requirements
Most Common Chiropractic ICD-10 Codes
Chiropractors frequently use spinal and musculoskeletal diagnoses such as M54.2 (cervicalgia), M54.5 (low back pain), and M62.83 (muscle spasm). Each diagnosis must align with the CPT code billed.
CPT Codes Essential to Chiropractic Medical Billing
Chiropractors primarily rely on adjustment codes 98940–98942, along with therapy codes such as 97110 and 97140 when appropriate. Therapy codes must show measurable improvement to qualify as covered.
Mandatory Documentation Elements
To support medical necessity, chiropractors must maintain:
Treatment plan outlining goals, frequency, and duration
SOAP notes for every visit
Medical necessity justification connecting diagnosis to treatment
Progress notes documenting measurable improvement
Outcome assessments like pain scales or ROM measurements
People Also Ask (Explained In-Depth)
Does Insurance Cover Chiropractic Services?
Insurance often covers chiropractic adjustments when medically necessary, but coverage for modalities, X-rays, or maintenance care varies widely.
What Documentation Is Required for Chiropractic Claims?
Insurers require a treatment plan, detailed SOAP notes, clinical findings, objective measures, and justification of medical necessity.
Why Do Chiropractic Claims Get Denied?
Common reasons include insufficient documentation, incorrect modifiers, lack of medical necessity, or frequency limitations.
How Often Can a Chiropractor Bill 98940, 98941, or 98942?
Frequency depends on the payer. Many insurers limit adjustments per week or per episode of care.
What’s the Difference Between Chiropractic and Physical Therapy Billing?
PT billing uses time-based codes exclusively. Chiropractic billing revolves around spinal regions and has stricter coverage limitations.
What Is the Average Reimbursement Rate for Chiropractic Visits?
Reimbursement varies from $25–$75 for adjustments depending on region, payer, and CPT code.
Step-by-Step Guide to Chiropractic Medical Billing
Step 1 — Verify Patient Insurance & Coverage Limits
Check benefits, exclusions, chiropractic caps, deductibles, and active-care requirements.
Step 2 — Identify the Correct ICD-10 and CPT Codes
ICD-10 codes must align with spinal regions treated and CPT codes used.
Step 3 — Complete Documentation to Support Medical Necessity
Document exam findings, functional limitations, and measurable improvements.
Step 4 — Submit Claims to Payers (Electronic or Paper)
Ensure proper modifiers (AT, 59, GP) are included when required.
Step 5 — Monitor Claims and Handle Rejections
Correct errors quickly to prevent aging accounts receivable.
Step 6 — Manage Patient Statements and Balances
Send timely statements and clarify non-covered services.
Step 7 — Maintain Compliance With Chiropractic Billing Regulations
Follow Medicare, commercial payer, and state-specific rules.
Table: Chiropractic CPT Codes and Their Usage Rules
| CPT Code | Description | Usage Notes | Limitations |
|---|---|---|---|
| 98940 | 1–2 regions | Minor adjustments | May require strong documentation |
| 98941 | 3–4 regions | Commonly used | Requires detailed SOAP notes |
| 98942 | 5 regions | Complex adjustments | Payers often limit frequency |
| 97010 | Hot/cold therapy | Non-covered by many payers | May need ABN |
| 97110 | Therapeutic exercise | Requires measurable progress | Time-based |
| 97140 | Manual therapy | Must avoid code conflicts | Modifier 59 often needed |
Chiropractic Medical Billing Compliance & Audit Prevention
Common Red Flags in Chiropractic Billing
Billing maintenance care as active care
Upcoding adjustment levels
Missing progress notes
Excessive frequency
How to Avoid Medical Necessity Denials
Tie symptoms, diagnosis, and treatment together using objective measurements.
Correct Use of Modifiers (e.g., 59, AT, GP)
AT = active treatment
59 = separate, distinct service
GP = therapy under a plan of care
Documentation Practices That Protect Against Audits
Maintain thorough treatment plans, SOAP notes, and update progress every 30 days.
Table: Chiropractic Documentation Checklist
| Documentation Element | Required? | What It Must Include |
|---|---|---|
| Treatment Plan | Yes | Goals, duration, outcomes |
| SOAP Notes | Yes | S/O/A/P details |
| Initial Assessment | Yes | Exam, diagnosis |
| Progress Notes | Yes | Improvement metrics |
| X-Ray Justification | Optional | Clinical necessity |
| Outcome Measures | Recommended | Pain scales, ROM |
Benefits of Outsourcing Chiropractic Medical Billing
Faster Reimbursements
Billing specialists reduce errors and accelerate claim processing.
Higher Claim Acceptance Rate
Experts know payer-specific rules.
Reduced Administrative Burden
Chiropractors focus on patient care instead of paperwork.
Better Compliance and Audit Protection
Outsourcing reduces risk by ensuring consistent documentation and coding.
Chiropractic Medical Billing vs. In-House Billing
| Factor | In-House Billing | Outsourced Billing |
|---|---|---|
| Cost | Salary + overhead | Flexible fee |
| Expertise | Varies | Chiropractic experts |
| Denial Rate | Higher | Lower |
| Compliance | Requires training | Constantly updated |
| Efficiency | Limited | High |
Tools and Software Used in Chiropractic Medical Billing
EHR & Practice Management Systems
Tools like ChiroTouch or Jane streamline documentation and scheduling.
Billing Software With Chiropractic-Specific Features
Includes billing templates, carrier rules, and modifier suggestions.
Automated Coding Tools
Reduce coding errors and speed up claim creation.
Clearinghouse Systems
Check claims for errors before submission.
FAQs About Chiropractic Medical Billing
1. What is the AT modifier and when is it required?
The AT modifier indicates active treatment and is required for Medicare-covered adjustments.
2. Why are chiropractic claims often denied for “lack of medical necessity”?
Denials occur when documentation doesn’t show objective improvement.
3. Are chiropractic X-rays covered by insurance?
Coverage depends on payer and medical necessity.
4. What is the difference between maintenance therapy and active care?
Maintenance care preserves health; active care treats injury or dysfunction.
5. How long does it take to get reimbursed?
Typically 7–30 days depending on payer.
6. Can chiropractors bill E/M codes?
Yes, when an evaluation is medically necessary and documented.
7. How often can you bill therapeutic modalities?
Frequency must match clinical need and payer policy.
8. What’s the best software for chiropractic billing?
Options include ChiroTouch, Eclipse, Jane, and Platinum.
9. Can chiropractic assistants do documentation?
They may assist, but providers must finalize clinical documentation.
10. What modifiers are commonly required?
AT, GP, and 59 are most common.
Conclusion
Accurate chiropractic medical billing is essential for maximizing reimbursement, preventing denials, and maintaining compliance. When chiropractors combine strong documentation, proper coding, and efficient billing processes or outsource to specialists they not only protect their practice but also improve patient care and overall financial performance. For more information visit AAAMB.