A narrow Medicare benefit and many other payers
Chiropractors are licensed providers whose insurance coverage is narrower than most physicians’. Medicare pays doctors of chiropractic only for manual manipulation of the spine to correct a subluxation, and only while treatment is active and corrective. Commercial plans set visit limits and authorization rules, and many practices also treat auto injury and workers’ compensation patients, each with their own claim requirements. Knowing what each payer actually covers, before the visit, is the core of chiropractic billing.
Manipulation codes
| Code | Service | Medicare |
|---|---|---|
| 98940 | Spinal manipulation, 1–2 regions | Covered for subluxation when active/corrective |
| 98941 | Spinal manipulation, 3–4 regions | Covered for subluxation when active/corrective |
| 98942 | Spinal manipulation, 5 regions | Covered for subluxation when active/corrective |
| 98943 | Extraspinal manipulation | Not covered when performed by a chiropractor |
The code depends on the number of spinal regions treated, and each region needs a supporting diagnosis and documented findings. Examinations, X-rays and therapies such as exercise or modalities are not covered by Medicare when ordered or performed by a chiropractor, although many commercial plans cover them.
Medicare modifiers and advance notices
- AT on manipulation that is active/corrective treatment; without AT, Medicare treats it as maintenance therapy and does not pay.
- GA when an Advance Beneficiary Notice was signed for care Medicare is expected to deny as not medically necessary, such as maintenance therapy; GZ when no notice was obtained.
- GY for services that are statutorily excluded, such as chiropractic exams or therapies, so they can be billed to the patient or a secondary payer.
- Documentation: subluxation demonstrated by X-ray or by physical examination, commonly documented with the PART elements — pain, asymmetry, range-of-motion abnormality and tissue changes — with a treatment plan and measurable goals.
Commercial, auto and workers’ compensation claims
Commercial plans often cover examinations, E/M visits with modifier 25 when separately supported, and therapies, but limit visits per year or require authorization through a utilization-management vendor. Auto injury claims follow state personal-injury rules and may involve attorneys and liens, while workers’ compensation follows state fee schedules and needs the claim and adjuster details. Each chiropractor must be credentialed with each plan before seeing its patients.