Chiropractic Billing in 2025: A Practical Guide to Codes, Claims, and Maximizing Reimbursements

When individuals envision chiropractors, they frequently picture a few adjustments of the spine and neck, leading them to believe that the billing process is equally uncomplicated. However, if you consult anyone working in the billing department of a chiropractic office, they will inform you that it is fraught with complexities involving CPT codes, ICD-10 diagnoses, payer regulations, documentation of medical necessity, and fluctuating reimbursement rates.

As of 2025, the billing for chiropractic services has become more precise and regulated than ever. The increase in scrutiny of claims, combined with adjustments in CMS reimbursement, necessitates that providers remain vigilant, both in their clinical practices and in their administrative precision.

Grasping the Basics of Chiropractic Billing

Chiropractic billing initiates with the accurate assignment of CPT (Current Procedural Terminology) codes corresponding to the services rendered and ICD-10-CM codes for the diagnoses. However, it is important to note that chiropractic billing differs significantly from billing in general medicine. Payers, especially Medicare, impose stringent restrictions on what is covered and what qualifies as “medically necessary.”

Below is an overview of the primary CPT codes utilized in chiropractic billing:

Most chiropractic practices rely on these codes; however, the number of regions treated must be accurately documented and must align with the active symptoms recorded by the ICD-10 codes.

Common ICD-10 Codes in Chiropractic Billing

ICD-10 codes must always substantiate medical necessity. Below are some of the most frequently utilized diagnoses:

Pro Tip: Avoid using generic codes such as “M54.9 Back pain, unspecified” unless necessary. Patients dislike ambiguous diagnoses.

Reimbursement Landscape in 2025

Overall, the reimbursement rates for chiropractic services have been rather limited; nonetheless, CMS and various private insurers have implemented minor modifications to the fee schedules in 2025 for those providers who demonstrate clear documentation and compliance.

The following is a new forecast for 2025 regarding national average reimbursement rates:

Note: These figures are based on Medicare. Rates from commercial insurance may be 10–25% higher, contingent upon the payer and contract terms.

Significant Change in 2025: Documentation Enforcement

One of the most significant changes in 2025 is Medicare’s “Documentation Compliance Audit Initiative” for chiropractors. Random post-payment reviews are becoming more prevalent, and CMS has refined the definition of “maintenance therapy,” which is not eligible for reimbursement.

To ensure payment, chiropractors must now clearly demonstrate:

• Initial treatment plan with short-term objectives.
• Re-evaluation of the schedule every 30 days or sooner.
• Subjective and objective findings, not merely patient complaints.
• Utilization of outcome assessments (such as Oswestry or NDI).

Common Billing Pitfalls in 2025 (and How to Avoid Them)

• Missing Diagnosis Linkage: Utilizing a diagnosis code that is not related to the adjusted spinal region.
• Overusing M54.5: While it is popular, excessive use raises red flags.
• Absence of AT Modifier for Medicare: If you neglect to include it, your claim will likely be rejected.

Pro Tip: Always verify that each CPT code has a corresponding ICD-10 that supports it, and ensure your documentation can substantiate it.

Mastering Modifiers, Audits & Payer-Specific Regulations Like an Expert

We have addressed the fundamentals: CPTs, ICDs, and reimbursement rates. However, any experienced chiropractic biller will affirm that it is the modifiers and payer-specific details that determine the success of clean claim submissions. A single error can lead to rejections, denials, or, even worse, pre-payment audits.

Let us navigate through the complexities and explore how to code intelligently in 2025, while remaining vigilant against audit flags.

Decoding the Most Important Modifiers in Chiropractic Billing

For chiropractors, one specific modifier can be either your greatest ally or your most significant adversary if overlooked.

1. Modifier AT: Active Treatment

• Required for all Medicare claims related to spinal manipulation (98940–98942).
• Signifies that the treatment is medically necessary rather than maintenance.
• In its absence, Medicare will reject your claim as “maintenance therapy.”

Tip: A valid treatment plan and measurable objectives are essential to substantiate this modifier. If there is no progress in the patient’s condition, it may be flagged, even with the AT modifier in place.

1. Modifier GA: Waiver of Liability

• Utilized when you anticipate that Medicare may not cover the costs, and the patient has signed an ABN (Advance Beneficiary Notice).
• Demonstrates that the patient comprehends and consents to pay if the claim is denied.

1. Modifier GY: Non-Covered Services

• Applied when billing for services that are never reimbursed by Medicare, such as maintenance care or non-spinal adjustments (e.g., 98943).

1. Modifier 25: Significant, Separately Identifiable E/M

• If a patient undergoes an examination and an adjustment on the same day, this modifier should be used alongside an E/M code (99202–99215).
• Separate documentation for both the evaluation and the manipulation is required.

Navigating the 2025 Audit Wave

The Office of Inspector General (OIG) and CMS are focusing more on chiropractors in 2025. The reason for this increased scrutiny is that audits conducted in 2023–24 uncovered significant error rates in chiropractic claims, particularly concerning the improper application of AT modifiers, insufficient documentation, and the misclassification of maintenance therapy as active care.

Here are the issues that payers are highlighting in 2025:

• Frequent repetition of the same diagnosis codes over several months.
• Absence of documented improvement in SOAP notes.
• Extended care without a re-examination or discharge plan.
• Billing for spinel manipulation at every visit without clinical justification.

To safeguard your practice: Conduct regular internal audits every quarter. Utilize audit tools or engage external coders for random chart evaluations. This minor investment can lead to substantial savings on recoupments.

Chiropractic Billing Payer-Specific Guidelines for 2025

In contrast to Medicare, which poses the greatest challenges for chiropractic billing, private payers also present their complexities. Each has its unique requirements:

What About Extraspinal Adjustments?

A notable source of confusion exists: CPT 98943 (extraspinal manipulation) is not covered by Medicare, and many insurers limit its use or require specific justification. Consider the knee, shoulder, elbow, and TMJ; all of these are classified as extraspinal.

Advice: When billing for 98943, associate it with a specific diagnosis code relevant to that area, such as:

• 511: Pain in the right shoulder
• 571: Pain in the right ankle
• 604: Pain in the right leg

Utilize modifier 59 if billed on the same day as a spinal CMT to indicate it is a separate procedure.

Practical Advice: Maintain a Billing “Cheat Sheet”

Have either a physical or digital quick-reference guide at your billing station that includes:

• Frequently used CPTs and ICDs
• Corresponding modifiers for each code
• Payer-specific peculiarities (particularly for BCBS, UHC, and Medicare)
• Maximum permitted visits per plan

Keep in mind: The majority of denials arise not from incorrect procedures but from improper documentation or coding.

Coding Scenarios, Denial Management & Reimbursement Realities

Let us engage in a hands-on approach and explore practical coding scenarios, strategies for addressing issues when they arise, and the implications of the new reimbursement adjustments for your financial outcomes this year.

Chiropractic Evaluation & Management (E/M) Codes

Though spinal adjustments form the foundation of chiropractic practices, many chiropractors also conduct initial examinations and follow-up assessments, whether for new patients or those undergoing treatment. This is where E/M codes are applicable.

The following are the most common codes:

Tip: When billing for an E/M visit on the same day as a chiropractic adjustment, utilize modifier 25, ensuring that the evaluation was distinctly identifiable (for instance, a new condition or a different injury area).

Real-World Coding Examples

Scenario 1:

• Patient Complaint: Mid and lower back pain
• Exam Findings: T7–T9 and L4–L5 dysfunction
• Service Rendered: Chiropractic manipulation to the thoracic and lumbar regions

Claim:

• CPT: 98941 (3–4 spinal regions)
• ICD-10: M99.03, M99.05, M54.5
• Modifier: AT (if Medicare)

Scenario 2:

• Patient Complaint: Neck pain and left shoulder stiffness
• Service Rendered: Cervical adjustment and extraspinal manipulation of the left shoulder

Claim:

• CPT: 98940 + 98943
• ICD-10: M54.2, M25.512
• Modifiers: 59 (on 98943), AT (if Medicare — but note, 98943 is non-covered)

When Claims Are Denied: What Should You Do?

Even if you follow all the correct procedures, denials can still occur, particularly with the automated claim review systems prevalent today. Here is a workflow to implement in 2025:

List of Checks for Chiropractic Denials:

1. Avoid rushing through the EOB: Is it a denial due to coverage or a coding mistake?
2. Conduct a Common Error Check:

• Absence of modifier (AT or 25 typically)
• Unreliable ICD connection
• Incorrect diagnosis (for instance, unspecified or chronic codes that do not indicate an acute flare-up)

3. Review Documentation: Was the SOAP note organized and comprehensive?
4. Time for the Appeal Letter: Submit within 30–45 days, including:

• Appropriate documentation
• Clarification of medical necessity
• Emphasis on guidelines if the payer misinterpreted the coding

Pro Tip: Have templates prepared for appeal letters. This will save time and enhance your chances of quickly overturning denials.

Reimbursement Changes in 2025: What is the Conclusion?

However, this increase comes with conditions: additional compliance regulations, outcome tracking, and prior authorization requirements.

Here is how the situation has evolved:

However, it is not solely about the rates; payers are demanding more evidence of effectiveness.

Some changes that will take effect in 2025 include:

• United Healthcare and Cigna now mandate a minimum of two outcome assessment scores every 30 days.
• Certain BCBS plans are testing pre-payment reviews for high-volume providers.
• CMS is suggesting a future MIPS-like program for chiropractors, which could link future reimbursements to clinical outcomes and cost-effectiveness.

Essential Strategies for Maintaining Profitability in 202

• Ensure regular updates.
• Avoid dependence on mere adjustments. E/M codes can enhance revenue when utilized in compliance.
• Train your front desk and billing staff on essential coding principles. An erroneous entry can lead to a loss of revenue.
• Invest in billing software equipped with chiropractic templates, audit tracking, and modifier notifications.

Keep in mind: 80% of chiropractic audits in 2024 led to claim recoupments. In 2025, the focus should not be on increasing patient numbers; rather, it should be on improving coding accuracy and ensuring cleaner claims.

FAQs, Billing Reference Guides & Staying Proactive

As we conclude this comprehensive exploration of chiropractic billing, one fact stands out: 2025 emphasizes accuracy, evidence, and readiness. Chiropractors who dedicate time to proper coding, thorough documentation, and comprehension of the regulations will not only receive payments more swiftly but will also evade pitfalls that could result in audits and revenue decline.

To simplify your daily operations, let us review a practical reference guide, address frequently asked questions, and conclude with a billing-oriented mindset for the remainder of the year.

Your 2025 Chiropractic Billing Reference Guide

Frequently Asked Questions (FAQs)

Q1. Can chiropractors bill for therapeutic modalities (e.g., ultrasound, manual therapy)?

Yes, services such as 97140 (manual therapy) or 97012 (mechanical traction) can be billed when clinically warranted. However, many payers necessitate a clear distinction from manipulation and a connection to diagnosis. Utilize modifier 59 if necessary.

Q2. Is there a limit on the number of chiropractic visits allowed each year?

Medicare does not impose a strict limit, but ongoing visits must demonstrate progress. Most private insurers restrict visits to 10–20 annually, unless preauthorization is obtained or a revised treatment plan is provided.

Q3. What is the most effective method to establish “medical necessity”?

• Employ region-specific ICD-10 codes
• Record objective findings (e.g., palpation, range of motion, orthopedic assessments)
• Specify treatment objectives and update them consistently
• Perform periodic re-evaluations

Q4. What occurs if I neglect to include the AT modifier on a Medicare claim?

The claim is likely to be rejected as maintenance care. You may correct and resubmit it, but repeated omissions could lead to pre-payment audits or loss of privileges with CMS.

Real Talk: Maintaining Profitability in 2025 Without Incurring Losses

Chiropractors frequently exert considerable effort for relatively low reimbursement rates. This implies that every under-coded visit or overlooked modifier adversely impacts your revenue.

Here is what high-performing clinics are implementing this year:

• Conduct internal audits every 30–60 days
• Bundle services intelligently, utilizing CMT + E/M visits when suitable
• Educate your front desk staff on coverage policies, ABN usage, and modifier requirements
• Implement billing software equipped with alerts for missing documentation or modifier mistakes

Advice from a billing coach:

“Do not merely learn codes. Understand patterns. Recognize what payers favor and what causes them to scrutinize. That is where the true revenue lies.”

Essential Tools for 2025

• Cheat Sheets for CPT/ICD codes, modifiers, and common visit combinations
• Audit Logs: Document when and how treatment plans were modified
• Billing Dashboards: Visualize claims that are pending, denied, or approaching appeal deadlines

Concluding Thoughts: Integrating Billing with Improved Outcomes

While billing may not possess the allure of the adjustment table, it remains equally crucial in 2025. The effectiveness of your care hinges on proper payment, and maintaining awareness of documentation, coding updates, and payer trends is essential for safeguarding your practice, your license, and the continuity of care for your patients.

Thus, view this as your billing adjustment: minor modifications today can result in long-term alignment within your revenue cycle. For comprehensive and current insights regarding medical coding and billing, explore additional articles on the website, and remember to contact MedEx MBS for guaranteed accurate reimbursement for your services.

Summary Table of Key Points

Why choose MedEx MBS for Chiropractor Billing?

• Over 9+ years of expertise in medical billing
• Dedicated account managers for tailored support
• Weekly meetings to monitor denials and payments
• System-agnostic: We collaborate with all EHR and PM systems
• Flexible pricing structures