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Successful reimbursements are the top priority for most healthcare providers.

Getting paid by insurance payers without any delay is like hitting the jackpot for healthcare providers.

However, providers and medical practices must follow specific rules to reach this goal.

The foundation of successful billing and comprehensive Revenue Cycle Management (RCM) lies in accurate coding, documentation, and detailed claims.

Medical codes and their modifiers are key to ensuring that claims are successfully submitted and appropriately reimbursed by payers. 

In this blog, we will discuss the CPT codes and modifiers in chiropractic billing. As well as the guidelines for chiropractors to follow for optimal reimbursement.

Chiropractic Billing CPT Codes

Before proceeding to the modifiers used in chiropractic billing, chiropractors need to understand the CPT codes to reimburse the services accurately. 

CPT codes are vital in the billing process for chiropractors, clearly indicating to the insurance company the procedures performed and what the provider seeks reimbursement for.

While other medical providers might use a wide array of CPT codes, chiropractors typically utilize four main codes, each reflecting the specific region of the spine treated:

• CPT Code 98940: Chiropractic manipulative treatment (CMT); Spinal, 1-2 regions
• CPT Code 98941: Chiropractic manipulative treatment (CMT); Spinal, 3-4 regions
• CPT Code 98942: Chiropractic manipulative treatment (CMT); Spinal, 5 regions
• CPT Code 98943: Chiropractic manipulative treatment (CMT); Extraspinal, 1 or more regions

It’s crucial to document the number of regions treated on your forms accurately. For instance, CPT code 98942 indicates treatment in 5 areas, but only documenting 3-4 treated regions will likely result in a claim rejection by the insurance company.

Modifiers in Chiropractic Billing

Billing in chiropractic care is not just about submitting codes; it’s about ensuring accurate communication with insurers.

Modifiers are essential tools for this communication.

They clarify why, when, and how a procedure was performed, preventing denials and ensuring reimbursement.

Let’s explore the essential modifiers in chiropractic billing.

1). Modifier 25

Modifier 25 is used when an evaluation and management (E/M) service is performed on the same day as another procedure, and the service is distinct and necessary.

While using this modifier, you tell the insurer, “Hey, this isn’t just bundled into the procedure—it’s a distinct service.” Without this modifier, the E/M service may be bundled into the primary procedure, leading to denial.

Example ➜ Imagine a patient walks in for their regular chiropractic adjustment (CPT code 98941), but during the visit, they also complain about new back pain after a recent fall. You conduct a detailed evaluation to diagnose a potential strain and document it. You’d append Modifier 25 to the E/M service code (e.g., 99203) to indicate that the evaluation was separate and warranted beyond the adjustment.

Chiropractic care often involves adjustments and evaluations to address new or evolving issues. Modifier 25 distinguishes when the evaluation is a necessary and distinct service, not just part of routine care.

• When to Use: This modifier applies if you assess a patient for a new complaint or significantly re-evaluate a pre-existing condition during a session that also involves a procedure like a spinal adjustment.
• Documentation Requirements: Detailed notes must reflect the separate time, effort, and reasoning behind the evaluation.

⭐ Pro Tip: Don’t misuse Modifier 25 to bill for routine services bundled into the adjustment. Insurers scrutinize claims, so documentation must show the necessity of the E/M service separately.

2). Modifier 59

Modifier 59 is essential when billing two procedures, usually bundled but performed independently in distinct circumstances. It is most commonly used to unbundle procedures typically billed together. This modifier prevents payers from automatically combining services and reducing reimbursement.

Modifier 59 is like waving a flag to say, “These are two separate services, even though they might look related.”

Example ➜ Let’s say you provide manual therapy (CPT code 97140) alongside a spinal manipulation (CPT code 98940) in the same visit. Medicare guidelines often consider these services bundled unless performed on separate anatomical regions. To indicate this distinction, you’d append Modifier 59 to 97140.

In chiropractic care, multiple procedures can overlap in purpose but may target different regions or conditions. Modifier 59 separates these services to ensure they’re recognized as individual treatments.

• When to Use: This modifier is applied to the secondary service that would typically be denied as bundled unless you demonstrate its distinct necessity.
• Documentation Requirements: Clear records showing the different regions treated or separate times for the procedures are required.

⭐ Pro Tip: Use Modifier 59 sparingly and appropriately. Overusing it can trigger audits faster than you can say, “insurance claim denied.”

3). Modifier GA

Modifier GA is used when Medicare may not cover a service, and the patient has signed an Advance Beneficiary Notice (ABN) acknowledging their financial responsibility. This modifier is essential for chiropractors working with Medicare, where some services are often deemed medically unnecessary.

Modifier GA tells the insurer, “I informed the patient that this service may not be covered, and they signed an Advance Beneficiary Notice (ABN).”

Example ➜ If you perform maintenance therapy (a service Medicare doesn’t usually cover), you must notify the patient upfront. Once they sign the ABN, you append Modifier GA to the code for the service. If Medicare denies the claim, the patient is responsible for payment.

Medicare often denies claims for maintenance therapy or other non-covered services. This modifier is Medicare’s way of verifying that you’ve communicated the coverage limitations to the patient beforehand.

• When to Use: Whenever you suspect Medicare may deny a service as “not medically necessary.”
• Documentation Requirements: Keep the signed ABN in the patient’s file as evidence of informed consent.

⭐ Pro Tip: Always keep the ABN on file and ensure the patient fully understands their financial responsibility before proceeding with the service.

4). Modifier GY

Modifier GY explicitly tells Medicare that the billed service is excluded from coverage under their policies. It’s a proactive declaration that prevents confusion and speeds up claims processing.

Consider Modifier GY as a heads-up to Medicare that you’re billing for something explicitly excluded from coverage. It saves time and ensures the claim is processed correctly.

Example ➜ If a patient requests a service like a massage therapy session (which Medicare doesn’t cover), you would append Modifier GY to the relevant CPT code. This lets Medicare know it’s not a covered benefit, and the patient will be billed directly.

This modifier applies when billing services outside Medicare’s chiropractic benefit, such as nutritional counseling, acupuncture, or massage therapy.

• When to Use: For non-covered services requested by the patient or fall outside Medicare’s scope of chiropractic coverage.
• Documentation Requirements: Although no ABN is needed, it’s good practice to note that the patient was informed about non-coverage.

⭐ Pro Tip: Unlike Modifier GA, you don’t need an ABN for Modifier GY services. However, good communication with patients is still critical to avoid surprises.

5). AT Modifier

The AT Modifier is exclusively for Medicare claims and distinguishes active treatment from maintenance therapy. Medicare only reimburses spinal manipulations deemed necessary for improving function or alleviating pain.

The AT Modifier is Medicare’s way of identifying spinal manipulations that are medically necessary for active treatment instead of maintenance care. Chiropractors must use this modifier on Medicare claims even when considering them.

Example ➜ A patient comes in with acute low back pain due to sciatica. You perform spinal manipulation (CPT code 98941) as part of a treatment plan designed to improve function and reduce pain. Attaching the AT Modifier indicates this is an active care service, not routine maintenance.

This modifier signals that the care provided is part of an active treatment plan addressing a specific diagnosis instead of maintenance therapy, which Medicare does not cover.

• When to Use: Whenever billing spinal manipulation codes (CPT 98940-98942) for patients with acute or chronic conditions requiring active care.
• Documentation Requirements: Include treatment plans, progress notes, and diagnoses to demonstrate the need for active treatment.

⭐ Pro Tip: If you forget to add the AT Modifier, Medicare might deny the claim outright, assuming it is maintenance therapy. Permanently attach it for active care!

Modifier Usage Guidelines for Chiropractic Services Providers

Using the right modifiers in billing can help you get paid quickly and avoid claim problems. Here are five simple rules to follow when using modifiers for chiropractic services:

1️⃣ Know Insurance Rules

Different insurance companies have different rules for modifiers. For example, Medicare requires Modifier AT to show that the treatment is for active care, not just maintenance. Learn the rules for each insurance provider you work with to avoid mistakes and denied claims.

2️⃣ Write Clear Physician Notes for Each Service

Good notes are very important for billing. For example:

• Modifier 25: If you use this modifier, your notes should explain why the exam was needed and separate from the adjustment.
• Modifier 59: When using this, explain that the two treatments were done in different areas of the body or at different times. Clear, detailed notes help show that your modifiers are used correctly.

3️⃣ Use Modifiers Carefully

Modifiers should only be used when necessary. Using them too much or in the wrong way can cause problems with your claims. For Modifier 59, only use it if two services are truly separate and done for different reasons. If the treatments are related, don’t use this modifier.

4️⃣ Keep Up with Coding Changes

CPT codes and insurance rules change often. Make sure you stay updated on these changes so you use the right modifiers. You can join coding workshops or sign up for chiropractic billing newsletters to learn about updates.

5️⃣ Train Your Billing Team

Your billing team is important for making sure claims are correct. If they don’t know how to use modifiers, it could cost you money. Make sure your team gets regular training on using modifiers and writing clear notes. This will help your claims get approved faster and reduce mistakes.

By following these simple rules, you can avoid mistakes in billing, get paid on time, and keep your practice running smoothly.

Final Thoughts

Modifiers may seem small details, but they hold immense power in chiropractic billing.

Understanding and applying Modifiers 25, 59, GA, GY, and AT ensures clear communication with payers and prevents unnecessary denials.

By pairing clear documentation with the correct use of these modifiers, chiropractors can stick to their expertise—helping patients feel better—without the distraction of billing headaches.