Chiropractic Services

Affected Providers

Doctors of chiropractic who submit claims for chiropractic services.

HCPCS & CPT Codes

Article: Billing and Coding: Chiropractic/Chiropractor Services has the current HCPCS and CPT codes. Select your Medicare Administrative Contractor’s (MAC’s) article from the search results.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for chiropractic services is 33.6%, with a projected improper payment amount of $178.3 million.

Denial Reasons

Insufficient documentation accounted for 95.5% of improper payments for chiropractic services during the 2024 reporting period, while no documentation (2.4%), incorrect coding (0.7%), medical necessity (0.6%), and other errors (0.9%) also caused improper payments.

Preventing Denials

Meeting Medical Necessity Requirements for Acute & Chronic Subluxation

The patient must have a significant health problem in the form of a neuromusculoskeletal condition that needs treatment. The manipulative services must be directly related to the patient’s condition and provide reasonable recovery expectations or function improvement. The patient must have a subluxation of the spine as shown by X-ray or physical exam, as described in the Documentation Requirements section.

Most spinal joint problems fall into these categories:

• Acute subluxation — A patient’s condition is acute when they’re being treated for a new injury as identified by X-ray or physical exam. We expect the chiropractic manipulation to improve or stop the progression of the patient’s condition.
• Chronic subluxation — A patient’s condition is chronic when it’s not expected to significantly improve or resolve with further treatment (which happens with an acute condition) but the patient can expect some functional improvement if they continue therapy. Once the clinical status for a given condition has stabilized, without expecting other objective clinical improvements, further manipulative treatment is maintenance therapy, and we don’t cover payment.

Documentation Requirements

Initial Visit Documentation Requirements

History

The history the provider records in the patient record should include:

• Chief complaint, including the symptoms causing the patient to seek treatment
• Family history, if relevant
• Past medical history (general health, prior illness, injuries, hospitalizations, medications, surgical history)

Present Illness

Description of present illness, including:

• Mechanism of trauma
• Quality and character of symptoms or problem
• Onset, duration, intensity, frequency, location, and radiation of symptoms
• Aggravating or relieving factors
• Prior interventions, treatments, medications, and secondary complaints

Physical Exam

We recommend the P.A.R.T. (Pain/tenderness; Asymmetry/misalignment; Range-of-motion abnormality; and Tissue tone, texture, and temperature abnormality) evaluation process as the exam alternative to the earlier mandated demonstration of subluxation by X-ray, magnetic resonance imaging (MRI), or computerized tomography (CT). P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).

You may prove subluxation by a physical exam or X-ray. If you show a subluxation by a physical exam, we require you document 2 of these 4 criteria (1 must be asymmetry or misalignment or range of motion abnormality):

• P – Pain/tenderness: Evaluate the perception of pain and tenderness in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest with a painful response. You may show pain and tenderness through 1 or more of these: observation, percussion, palpation, and provocation. You may assess pain intensity using 1 or more of these: visual analog scales, algometers, and pain questionnaires.
• A – Asymmetry/misalignment: Show asymmetry or misalignment on a sectional or segmental level through 1 or more of these: observation (for example, posture and heat analysis), static palpation for misalignment of vertebral segments, and diagnostic imaging.
• R – Range of motion abnormality: As changes in active, passive, and accessory joint movements may increase or decrease sectional or segmental mobility, show range of motion abnormalities through 1 or more of these: motion palpation, observation, stress diagnostic imaging, range of motion, and other measurements.
• T – Tissue tone, texture, and temperature abnormality: Show changes in the characteristics of contiguous and associated soft tissue, including skin, fascia, muscle, and ligament, through 1 or more of these: observation, palpation, use of instrumentation, and test of length and strength.

Diagnosis

Primary

The primary diagnosis must be subluxation and must include the level, either stated or identified by a term describing subluxation. These terms may refer to either the condition of the spinal joint involved or the direction of position assumed by the bone named. The doctor of chiropractic must specify the precise level of subluxation to prove a claim for manipulation of the spine.

Specify the level of subluxation in the patient’s record in 1 of 2 ways:

• Listing the exact bones (for example, C5, C6)
• Listing the area may be enough if it involves only certain bones (for example, occipito-atlantal (occiput and C1 (atlas)), lumbo-sacral (L5 and sacrum), and sacro-iliac (sacrum and ilium))

X-Rays

We don’t require an X-ray to show the subluxation, but you can use an X-ray for this purpose if you choose.

The X-ray date must be reasonably close to (within 12 months before or 3 months after) starting treatment. In certain chronic subluxation cases (for example, scoliosis), we may accept an older X-ray if the patient’s health record shows the condition has existed longer than 12 months and there’s a reasonable basis for concluding it’s permanent.

An earlier CT scan or MRI are acceptable evidence if they show a subluxation of the spine.

Treatment Plan

The treatment plan should include these:

• Recommended level of care (visit duration and frequency)
• Specific treatment goals
• Objective measures to evaluate treatment effectiveness
• Date of the first treatment

Subsequent Visits Documentation Requirements

These documentation requirements apply whether the subluxation is shown by X-ray or by physical exam:

History

• Review of chief complaint
• Changes since last visit
• Systems review, if relevant

Physical Exam

• Exam of spine area involved in diagnosis
• Assessment of change in patient condition since last visit
• Evaluation of treatment effectiveness