Chiropractic billing: active care, maintenance, and Medicare

Chiropractic billing has one concept that drives many denials: the difference between active care and maintenance care. Payers, especially Medicare, cover treatment that is expected to improve the patient's condition. They generally do not cover care meant only to maintain it.

What Medicare covers for chiropractors

For chiropractors, Medicare Part B covers manual manipulation of the spine to correct a subluxation, when it is medically necessary. Services such as exams, x rays ordered by a chiropractor, and therapies are not covered by Medicare when performed by a chiropractor. Manipulation is billed with chiropractic manipulative treatment codes based on the number of spinal regions treated.

Active care vs maintenance

Active or corrective treatment is care expected to produce functional improvement. Medicare uses the AT modifier to show that the manipulation is active treatment. When the patient has reached maximum improvement and care continues only to prevent decline or maintain the current state, Medicare considers it maintenance, which is not covered.

• Add AT to manipulation codes only when the care is active or corrective.
• Document a treatment plan with goals that can be measured.
• Record progress at regular intervals and update the plan as the patient improves.
• Recognize when the patient has reached maximum improvement and change how care is billed.

The ABN and maintenance care

If you believe Medicare will not pay because care is maintenance, give the patient an Advance Beneficiary Notice of Noncoverage before the service, so they can choose whether to receive it and pay. Use the right modifier to show an ABN is on file. Without a valid ABN, the practice may not be able to bill the patient for the denied service.

Documentation that supports the claim

• The subluxation and the spinal regions treated, supported by exam findings or imaging.
• The patient's symptoms and how they affect daily function.
• Objective measures that show change over time.
• A treatment plan with frequency, duration, and goals.
• Clear notes for each visit linking the treatment to the plan.

Cash and insurance mix

Many chiropractic practices see both insured and cash paying patients. Keep fee schedules, insurance rules, and patient agreements consistent with payer contracts and state rules, and make sure non covered services are explained to patients in advance.

Common chiropractic errors

1. AT modifier on maintenance visits.
2. Number of regions billed does not match documentation.
3. Missing or outdated treatment plan.
4. Billing Medicare for exams or therapies performed by a chiropractor.
5. No ABN on file when maintenance care is provided to Medicare patients.

Commercial plans and Medicaid

Commercial plans and Medicaid programs set their own chiropractic rules. Many limit visits per year, some require authorization after a set number of visits, and some cover exams and therapies that Medicare does not. Check benefits for each patient, and track visits used so care does not continue past the limit without approval.

Where Afiable helps

Afiable bills chiropractic claims with the right codes and modifiers, checks visit limits and eligibility, and works denials with the documentation payers ask for. Book a free audit and we will review a sample of your chiropractic claims.

This article is general information for practice owners and managers. Payer policies and regulations change, so confirm current rules with each payer before acting.