Chiropractic billing services for Medicare, commercial and injury claims
Medicare pays a chiropractor for one thing: manual manipulation of the spine to correct a subluxation, billed as 98940, 98941 or 98942 with the AT modifier. Everything else on a chiropractic claim, from the exam to the X-ray to the therapy codes, depends on the commercial plan, the auto policy or the state.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · Last reviewed October 2026Standards we work under
In short: chiropractic claims turn on the Medicare limit to spinal manipulation, the AT modifier for active treatment, GA or GZ when care is maintenance, and a note that proves the subluxation and the progress at each visit. Commercial and injury cases add exam, therapy and extraspinal lines that each payer decides.
The chiropractic codes we bill most
| Code | Description | Notes |
|---|---|---|
| 98940 | Spinal manipulation, 1 to 2 regions | Medicare status A, global 000; AT for active care |
| 98941 | Spinal manipulation, 3 to 4 regions | Medicare status A, global 000; AT for active care |
| 98942 | Spinal manipulation, 5 regions | Medicare status A, global 000; AT for active care |
| 98943 | Manipulation of extraspinal regions | Medicare status N, not covered; commercial plans vary |
| 99202 to 99205 / 99212 to 99215 | Office visit, new or established patient | Modifier 25 when separate; Medicare pays chiropractors only for manipulation |
| 97112 / 97124 / 97140 | Neuromuscular re-education, massage, manual therapy | Not separately reportable in a region undergoing manipulation (NCCI) |
| 72040 / 72100 | Spine X-rays, neck and lumbar | Medicare does not pay X-rays furnished or ordered by a chiropractor |
Modifiers that matter
| Modifier | Use |
|---|---|
| AT | Active or corrective treatment of acute or chronic subluxation on 98940 to 98942. Never on maintenance care. |
| GA | Signed ABN on file for care Medicare is expected to deny, such as maintenance. Leave AT off. |
| GZ | Denial expected and no signed ABN, provider liable. Never on the same line as GA. |
| 25 | Significant, separately identifiable visit on the day of a manipulation. Only on E/M codes. |
| 59 / XS | Therapy in a different region than the manipulation, only when the record shows it and the provider may report it. |
| GP | Physical therapy plan of care on always-therapy codes, required by UnitedHealthcare commercial policy. |
Payer rules to know
| Payer | Rule |
|---|---|
| Medicare | Spinal manipulation only; AT required on 98940 to 98942; one manipulation per day; GA or GZ with the ABN for maintenance care. |
| UnitedHealthcare | Commercial policy 2026R0119A: modifier 25 only on E/M codes; GN, GO or GP on always-therapy codes. |
| Palmetto GBA (Medicare) | Article A56616: M99.01 to M99.05 support necessity; only 1 chiropractic manipulation service per day is reimbursed. |
| Auto, no-fault and liability | Pays primary for accident-related care, including for Medicare patients; state fee schedules and filing limits apply. |
Top denials in chiropractic billing services for medicare, commercial and injury claims
| Reason | Why it happens | Our fix |
|---|---|---|
| CO-50 | Manipulation for a condition outside the covered rule in manual section 240.1.3, which includes maintenance care (CMS edit, MSN 15.4) | Check the chart for active treatment and expected improvement; add AT only if the note supports it. A missing AT is also denied as maintenance, so read the CARC and RARC your MAC sent |
| CO-16 | Item 14 blank, so the treatment or exacerbation date is missing (RARC MA122) | Add the date from the initial-visit note and resubmit |
| CO-B22 | Payment adjusted by the diagnosis, such as a condition not tied to the subluxation level billed | Make the primary diagnosis the subluxation at the level treated, with a matching secondary diagnosis |
| CO-97 | Exam or therapy line bundled into the manipulation payment | Confirm the visit was separate and add modifier 25, or the therapy was in another region and add 59 or XS |
| CO-151 | Records do not support the number or frequency of visits | Send the notes that show goals, progress and the treatment plan for the dates in question |
What does Medicare cover for chiropractors?
Medicare covers one chiropractic service: treatment by manual manipulation of the spine to correct a subluxation. 42 CFR 410.21(b) says Part B pays only for that service, and only when the subluxation has caused a neuromusculoskeletal condition for which manipulation is appropriate treatment.
The same regulation says Medicare does not pay for X-rays or other diagnostic or therapeutic services that a chiropractor furnishes or orders. Manual section 240.1.1 adds that a chiropractor's X-ray can support claims processing, but the film itself is not paid.
Hand-held manual devices are allowed, with no added payment for the device (section 240.1.1). A MAC pays only chiropractors on its reference file.
How many spinal regions can be billed per visit?
A visit gets one manipulation code, chosen by how many regions were treated. Manual section 240.1.4 lists five spinal areas: neck (occiput and cervical vertebrae), back (thoracic vertebrae and the rib joints), low back (lumbar), pelvis (the ilia) and sacral (sacrum and coccyx).
| Code | Regions treated | Medicare status in the October 2026 fee schedule file |
|---|---|---|
| 98940 | 1 to 2 | Status A, global period 000 |
| 98941 | 3 to 4 | Status A, global period 000 |
| 98942 | 5 | Status A, global period 000 |
| 98943 | Extraspinal regions, one or more | Status N, not covered by Medicare |
MLN Matters article SE1601 limits chiropractors to 98940, 98941 and 98942 under Medicare. The October 2026 CMS fee schedule file (RVU26D) gives them status A and a 000 global period, and gives 98943 status N, which its key defines as not covered by Medicare. A commercial plan sets its own rule for 98943 in the contract.
If the code says five regions, the note needs a subluxation level and a finding for each.
Only one treatment per day is paid. Section 240.1.5 limits reimbursement to not more than one treatment per day, and Palmetto GBA's article A56616 says the same.
What is the AT modifier and when do we leave it off?
AT is the HCPCS modifier for acute treatment, and the descriptor in the Medicare Coverage Database says it should be used when reporting 98940, 98941 or 98942. MLN Matters article SE1602 says every Medicare claim for those codes since October 1, 2004 needs AT when care is active or corrective, and MACs deny the codes without it.
Active care includes acute and chronic subluxation. Manual section 240.1.3 defines acute as a new injury where manipulation is expected to improve or stop the progress of the condition. Chronic means the condition will not improve much with more treatment, but continued therapy is expected to give some functional improvement.
Maintenance starts when the status is stable and no further objective improvement is expected. It includes care that prevents disease, promotes health, or keeps a chronic condition from getting worse. Medicare does not cover it, and AT must not be on the claim.
AT is a claim of active treatment, not proof of it. Section 240.1.3 says it may not in all instances indicate that the service is reasonable and necessary, and MACs may deny after review. SE1602 asks for a primary diagnosis of subluxation and a secondary diagnosis for the neuromusculoskeletal condition. Palmetto GBA's article A56616 lists M99.01 to M99.05 as supporting necessity in its jurisdiction; other MACs publish their own list in their LCD articles.
Palmetto GBA's LCD L37387 defines an acute exacerbation as a temporary but marked worsening that interferes with daily activities, and requires the record to give its date. That date goes in Item 14 of the CMS-1500.
When do we use GA and GZ for chiropractic?
Use GA when the patient signed an ABN before maintenance care, and GZ when you expect the denial and have no signed ABN. Section 240.1.3 of the manual says chiropractors who give or receive an ABN include a GA modifier on the claim, or in rare instances a GZ, and leave AT off. A line for 98940 to 98942 with no AT is treated as maintenance and denied.
| Situation | Modifier on the line | Who is liable if Medicare denies |
|---|---|---|
| Active or corrective care, documented | AT | Medicare reviews for payment |
| Maintenance care, ABN signed before the visit | GA, no AT | The patient (CMS chart: ABN required, beneficiary liable) |
| Maintenance care, no ABN, denial expected | GZ, no AT | The provider (CMS chart: expected denial, provider liable) |
The definitions come from the chart in section 60.4.2 of chapter 1 of the Claims Processing Manual. GZ cannot be used when an ABN was actually given, and chapter 23 section 20.9.1.1 says GZ and GA on the same item or service make the line unprocessable. Pick one.
CMS says the ABN transfers potential financial liability to the patient when Medicare payment is expected to be denied, with issuing rules starting at section 50 of chapter 30 of the Claims Processing Manual. Chapter 30 says GA shows the provider gave valid written notice before furnishing the service, so a form signed after the visit does not fit. See the ABN rule page.
On the remittance, group code PR means the patient owes the balance and CO means the provider does. The ABN has to be in the chart before the first maintenance visit, not found after the denial. The GA and GZ code pages carry the reference detail.
What documentation does a chiropractic practice need to support the codes billed?
Section 240.1.2 of the manual and MLN Matters article SE1601 set separate lists for the first visit and later visits, whether the subluxation is shown by X-ray or by physical exam.
Initial visit
- History: chief complaint, relevant family history, and past health history including injuries, hospital stays, medications and surgery.
- Present illness: mechanism of injury, character of symptoms, onset, duration, intensity, frequency, location and radiation, aggravating or relieving factors, and prior treatment.
- Symptoms tied to the level: a statement of "pain" is insufficient. Describe where it is and whether the vertebra listed can produce pain there.
- Physical exam showing the subluxation: two of the four P.A.R.T. findings, one of which must be asymmetry or misalignment, or a range of motion abnormality.
- Diagnosis: the primary diagnosis is the subluxation, with its level.
- Treatment plan: recommended level of care (duration and frequency), specific goals, and objective measures of effectiveness.
- The date of the initial treatment.
P.A.R.T. stands for pain or tenderness, asymmetry or misalignment, range of motion abnormality, and tissue tone, texture or temperature changes.
Every later visit
- History: review of the chief complaint, changes since the last visit, and a systems review if relevant.
- Exam of the spine area in the diagnosis, assessment of change in the condition, and evaluation of treatment effectiveness.
- The treatment given that day.
An X-ray has not been required since January 1, 2000. When one is used, section 240.1.2 says it should be taken no more than 12 months before or 3 months after treatment begins. A chronic condition such as scoliosis can use an older film if the record shows it is permanent, and an earlier CT or MRI that shows the subluxation is acceptable.
| CMS-1500 item | What Medicare expects (Claims Manual, chapter 12, section 220C) |
|---|---|
| Item 14 | Date of the initial treatment, or the date of exacerbation of the existing condition |
| Item 19 | Date of the X-ray, only when an X-ray is used to show the subluxation |
Section 220D of the same chapter tells MACs to edit for a missing Item 14 date, with CARC 16 and RARC MA122 on the remittance.
A made-up patient has low back pain tied in the chart to the lumbar spine and pelvis, with tenderness and lost motion at both.
How do we bill an exam with a manipulation?
Add modifier 25 to the visit only when the note shows a significant, separately identifiable service. Chapter XI of the 2026 NCCI Medicare Policy Manual says manipulation has a 000 global period and counts as a minor procedure, so a same-day E/M is included in its payment unless it is significant, separately identifiable and unrelated to the decision to perform it.
The same passage says the two do not need different diagnoses, and that a new patient is not enough on its own. Write the visit so its history and exam would still make sense if the manipulation were removed from the note.
Because 42 CFR 410.21(b) limits what Medicare pays a chiropractor to the manipulation, we do not build a Medicare claim around an exam line, and modifier 25 is not a way to force one through. Commercial plans decide in their own policies whether a visit is paid on the day of a manipulation.
UnitedHealthcare's commercial policy 2026R0119A says modifier 25 belongs on E/M codes, and its own example of a procedure code carrying 25 is one it does not reimburse.
Which therapy and extraspinal codes can a chiropractor bill with manipulation?
Commercial plans may pay a chiropractor for therapy codes, but NCCI limits them next to a manipulation. Chapter XI of the 2026 NCCI Medicare Policy Manual says 97112, 97124 and 97140 are not separately reportable when performed in a spinal region undergoing manipulation. In a different region, and if the provider is eligible to report physical medicine codes under the Medicare program, the pair can be reported with modifier 59 or XS.
| Code | Service in plain words | Same region as the manipulation | Different region |
|---|---|---|---|
| 97112 | Neuromuscular re-education | Not separately reportable | Modifier 59 or XS if eligible |
| 97124 | Massage | Not separately reportable | Modifier 59 or XS if eligible |
| 97140 | Manual therapy techniques | Not separately reportable | Modifier 59 or XS if eligible |
That passage names only those three codes. For 97110, 97530 and the rest, read the NCCI edit table and the plan's policy. Chapter 23 of the Claims Processing Manual bars 59 and XS from bypassing an edit unless the modifier's criteria are met and the record shows it.
Plan modifiers matter too. UnitedHealthcare's commercial policy requires GN, GO or GP on codes CMS designates as always therapy, regardless of who performs them, for dates of service from July 1, 2020. A therapy line from a chiropractic office therefore needs the matching modifier, usually GP, and a plan of care behind it. Timed-unit counting and KX are on the physical therapy billing page, and pain management covers injection bundling.
For 98943, Medicare's answer is no. Ask each commercial plan whether it pays the code on the same day as a spinal manipulation and whether it wants a modifier.
How do we bill personal injury and auto cases?
Bill the auto, no-fault or liability carrier first, using the same manipulation codes, region counts and documentation described above. CMS says that when a Medicare patient is injured in an accident, no-fault or liability insurance pays primary for the accident-related care and Medicare is secondary.
What changes is the paperwork and the state's fee schedule and filing limit, which are covered on the workers' compensation and no-fault billing page. A denial with CARC 19 means the payer believes the injury is work-related and belongs with the workers' compensation carrier.
What are the most common denial reasons in chiropractic and how are they worked?
The table above lists five reason codes to expect. Since insufficient documentation caused 95.5% of improper payments in CMS's 2024 data, most fixes start in the chart. We pull the note, check it against the visit lists above, and choose between a corrected claim and an appeal.
Reviewers check the diagnosis, code and modifiers on the claim face, then verify the benefit and necessity rules (SE1601).
How do Medicare and commercial payer rules differ for chiropractic claims?
| Topic | Medicare | Commercial plan |
|---|---|---|
| Covered services | Spinal manipulation only (42 CFR 410.21) | Set by the plan contract; exam, therapy or extraspinal lines may be paid |
| AT modifier | Required on 98940 to 98942 for active care | Follow the plan's policy; do not assume it is wanted or ignored |
| ABN, GA and GZ | Used for maintenance care | The ABN is a Medicare notice; commercial plans use their own patient responsibility rules |
Verify the plan type and chiropractic benefit before the first visit. Our Medicare and UnitedHealthcare guides cover those payers in more detail.
How we handle chiropractic billing at Nucleus Align
Our medical billing team includes AAPC and AHIMA certified coders. They code the region count from the note and set AT, GA or GZ against the ABN on file.
To talk through your practice, book a call.
- 42 CFR 410.21, Limitations on services of a chiropractor · eCFR
- Medicare Benefit Policy Manual, Chapter 15, section 240 Chiropractic Services · CMS
- Medicare Claims Processing Manual, Chapter 12, section 220 Chiropractic Services · CMS
- Medicare Claims Processing Manual, Chapter 1, section 60 (modifier chart) · CMS
- Medicare Claims Processing Manual, Chapter 23, section 20.9.1.1 · CMS
- MLN Matters SE1601: Medical record documentation requirements for initial and subsequent visits · CMS
- MLN Matters SE1602: Use of the AT modifier for chiropractic billing · CMS
- Medicare Provider Compliance Tips: Chiropractic Services · CMS
- 2026 NCCI Medicare Policy Manual, Chapter XI: Medicine and E/M Services · CMS
- Physician Fee Schedule relative value files, RVU26D (October 2026 release) · CMS
- Billing and Coding: Chiropractic Services (A56616) · CMS Medicare Coverage Database, Palmetto GBA
- Local Coverage Determination: Chiropractic Services (L37387) · CMS Medicare Coverage Database, Palmetto GBA
- Advance Beneficiary Notice of Non-coverage (ABN) · CMS
- Medicare Secondary Payer overview · CMS
- Procedure to Modifier Policy, Professional (commercial, 2026R0119A) · UnitedHealthcare
- Claim adjustment reason codes · X12
We check every rule, code and deadline against the official source. See our editorial policy.
Who we serve
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01How many spinal regions can be billed per visit?
One code per visit: 98940 for one to two regions, 98941 for three to four, and 98942 for five. The note needs a subluxation level for each region billed. Medicare pays one manipulation per day and does not cover 98943 for extraspinal areas.
02What does Medicare cover for chiropractors?
Manual manipulation of the spine to correct a subluxation, billed as 98940, 98941 or 98942 with the AT modifier. Under 42 CFR 410.21(b) Medicare does not pay for X-rays or other diagnostic or therapeutic services a chiropractor furnishes or orders. Maintenance care is not covered.
03When do we use GA and GZ for chiropractic?
Use GA when the patient signed an ABN before maintenance care, and GZ in rare cases when you expect a denial and have no signed ABN. Leave AT off both lines. Never send GA and GZ together, because the line becomes unprocessable.
04How do we bill personal injury and auto cases?
Bill the auto, no-fault or liability carrier first, with the same manipulation codes and documentation. CMS says no-fault and liability insurance pay primary for accident-related care, even for Medicare patients. State fee schedules and filing limits differ, and our workers' compensation and no-fault page covers them.
05How do we bill an exam with a manipulation?
Add modifier 25 to the visit only when the note shows a significant, separately identifiable service. NCCI treats manipulation as a minor procedure with a 000 global period, so the decision to treat is included in its payment. Medicare covers only the manipulation, so the exam is a commercial billing question.
06Which codes should a chiropractic billing team know best?
98940, 98941 and 98942 with AT, then GA and GZ for maintenance care and modifier 25 for a separate exam. Also know 98943, which Medicare does not cover, 97112, 97124 and 97140, which NCCI bars in the same region as a manipulation, and the M99.0x subluxation diagnoses.
07What are the most common denial reasons in chiropractic and how are they worked?
The usual ones are CO-50 for care outside the covered rule, such as maintenance, CO-16 for a blank Item 14, CO-B22 for a diagnosis that does not match the spinal level, CO-97 for bundled lines, and CO-151 for frequency. We read the remittance, pull the note, and correct the claim or appeal within 48 hours of the denial.
08What documentation does a chiropractic practice need to support the codes billed?
The first visit needs history, present illness, an exam showing subluxation (two of four P.A.R.T. findings), a diagnosis with the spinal level, a treatment plan with goals, and the start date. Later visits need changes since the last visit, an exam of the area, an evaluation of treatment effect, and the day's treatment.
09How do Medicare and commercial payer rules differ for chiropractic claims?
Medicare pays only spinal manipulation, requires AT on 98940 to 98942, and uses GA or GZ with the ABN for maintenance care. Commercial plans set coverage in the contract, so an exam, therapy code or 98943 may be paid, and some require therapy modifiers such as GP. Verify each plan's policy.
10Can the billing team work inside our existing EHR for chiropractic billing?
Yes. We align each EHR, clearinghouse and payer portal workflow with verified team experience, standard claim validation, reconciliation controls and performance monitoring. Tell us which chiropractic system you use when you book a call, and we will confirm how charges and remittances move.
Talk to a chiropractic billing services for medicare, commercial and injury claims billing lead.
A 20-minute call about your payers, volume and setup. Monday to Friday, 9am to 5pm Eastern.