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: CPT Code Description 98940 Chiropractic manipulation (1–2 spinal regions) 98941 Chiropractic manipulation (3–4 spinal regions) 98942 Chiropractic manipulation (5 spinal regions) 98943 Extraspinal manipulation (e.g., extremities such as the shoulder, knee, etc.) 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: ICD-10 Code Description M54.5 Low back pain M54.2 Cervicalgia (neck pain) M99.01 / M99.05 Segmental and somatic dysfunction (utilized to pinpoint spinal areas that need adjustment) M25.511 Pain in the right shoulder M79.1 Myalgia (muscle pain) 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: CPT Code 2025 Avg. Medicare Rate 98940 $27.60 98941 $39.80 98942 $50.90 98943 $25.00 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. 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. 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. 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). 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.