LCD Reference Article Billing and Coding Article

Billing and Coding: Chiropractic Services

A58345

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A58345
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Chiropractic Services
Article Type
Billing and Coding
Original Effective Date
10/01/2020
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual
    • Chapter 15, Sections 30.5 Chiropractor’s Services, 240 Chiropractic Services – General, 240.1 – Coverage of Chiropractic Services, 240.1.1 – Manual Manipulation, 240.1.2 – Subluxation May Be Demonstrated by X-Ray or Physician’s Exam, 240.1.3 – Necessity for treatment, 240.1.4 – Location of Subluxation, and 240.1.5 – Treatment Parameters
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 12, Section 220 Chiropractic Services
    • Chapter 30, Financial Liability Protections

Social Security Act (Title XVIII) Standard References: 

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Chiropractic Services.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.

When billing for Chiropractic services:

  • Report the initial treatment or date of exacerbation.
  • Specify the precise spinal location and level of subluxation.
  • Report the date of X-ray if an X-ray is used to demonstrate subluxation.
  • Report the level of subluxation using the appropriate ICD-10-CM code.
  • In addition to reporting the ICD-10-CM code for the level of subluxation, report any other pertinent ICD-10-CM codes.
  • All treatments must be categorized as acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either "acute" or "chronic" (e.g., an identifiable re-injury would fall under acute).


The following modifiers should be reported with CPT codes 98940, 98941, and 98942 as is appropriate to each patient's situation:

  • AT – Acute treatment
  • GA – Waiver of liability statement issued as required by payer policy, individual case. Authorization has been provided to notify the beneficiary of the likelihood that services rendered will be denied as not reasonable and medically necessary under Medicare guidelines. 
  • GZ – Item or service expected to be denied as not reasonable and necessary


For Medicare purposes, the AT modifier shall now be used only when chiropractors bill for active/corrective treatment.

  1. Every chiropractic claim (those containing CPT codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004 is to include the AT modifier if active/corrective treatment is being performed; or
  2. The AT modifier should not be appended to the service if maintenance therapy is being performed. Contractors shall deny a chiropractic claim (containing CPT codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004, that does not contain the AT modifier.


The mere presence of the AT modifier does not indicate that the service(s) are medically necessary. Reasonable and necessary requirements as addressed in the Medicare Internet-Only Manuals must be met.

Reasons for Denial

Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine. The chiropractor is not required to bill excluded services. However, if the beneficiary requests Medicare be billed, the provider must bill services to Medicare in order to obtain a denial for secondary insurance purposes. The following are examples (not an all-inclusive list) of services excluded from Medicare coverage when performed by a chiropractor; the beneficiary is responsible for payment.

  • Laboratory tests
  • X-rays
  • Office visits (history and physicals)
  • Physiotherapy
  • Traction
  • Supplies
  • Injections
  • Drugs
  • EKGs or any diagnostic study
  • Orthopedic devices
  • Nutritional supplements/counseling
  • Any service ordered by the chiropractor


Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

(3 Codes) >> Includes CHIRO
Group 1 Paragraph


Note
: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
Code Description
98940 Chiropract manj 1-2 regions
98941 Chiropract manj 3-4 regions
98942 Chiropractic manj 5 regions
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(12 Codes)
Group 1 Paragraph


It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 98940, 98941 and 98942.

Group 1 Codes
Code Description
M99.00 Segmental and somatic dysfunction of head region
M99.01 Segmental and somatic dysfunction of cervical region
M99.02 Segmental and somatic dysfunction of thoracic region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.05 Segmental and somatic dysfunction of pelvic region
M99.10 Subluxation complex (vertebral) of head region
M99.11 Subluxation complex (vertebral) of cervical region
M99.12 Subluxation complex (vertebral) of thoracic region
M99.13 Subluxation complex (vertebral) of lumbar region
M99.14 Subluxation complex (vertebral) of sacral region
M99.15 Subluxation complex (vertebral) of pelvic region
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph


All those not listed under the “ICD-10 Codes that Support Medical Necessity" section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
999x Not Applicable
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
99999 Not Applicable
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
08/21/2020 10/01/2020 - N/A Currently in Effect You are here

Keywords

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