Why do chiropractic claims keep getting denied even when your team believes the claim was submitted correctly? In many practices, several factors can cause a denial. Documentation gaps, coding problems, missing authorizations, benefit limitations, and payer-specific requirements can all affect claim processing.
The key is to treat recurring denials as patterns that your practice can identify and correct—not simply as individual claims that your staff must rework.
Why Do Chiropractic Claims Keep Getting Denied?
Chiropractic claim denials can originate at several points in the revenue cycle. A problem may begin during insurance verification, documentation, coding, claim submission, or follow-up.
Common areas to review include:
- Incomplete or unsupported documentation
- Incorrect CPT or ICD-10-CM coding
- Missing or inappropriate modifiers
- Authorization or referral requirements
- Coverage and benefit limitations
- Incorrect patient or insurance information
- Payer-specific claim requirements
- Missed appeal or correction deadlines
When the same denial reason appears repeatedly, look for the process that creates the problem instead of correcting each claim in isolation.
How Does Documentation Affect Chiropractic Claim Denials?
Documentation gives your billing team and the payer the information they need to understand what service your practice provided, why the provider performed it, and whether the claim meets the applicable coverage and documentation requirements.
For Medicare chiropractic services, CMS reports that insufficient documentation accounted for 95.5% of improper payments for chiropractic services in its 2024 reporting period. That statistic applies specifically to Medicare’s improper-payment review. It does not represent a universal denial rate for chiropractic practices or commercial payers.
CMS guidance calls for documentation of the patient’s history and present illness, relevant examination findings, diagnosis, treatment, and other information that supports the service. The clinical record should also support the diagnosis and services that your practice reports on the claim.
For Medicare chiropractic services, CMS describes the P.A.R.T. examination process as one method for documenting spinal subluxation through physical examination. When a provider uses P.A.R.T., CMS requires documentation of two of the four criteria. At least one criterion must involve asymmetry or misalignment or an abnormal range of motion.
- P — Pain/tenderness
- A — Asymmetry/misalignment
- R — Range-of-motion abnormality
- T — Tissue tone, texture, and temperature abnormality
These requirements apply specifically to Medicare. Do not assume that Medicare documentation rules apply automatically to every commercial payer or patient.
Can Coding Errors Cause Chiropractic Claims to Get Denied?
Yes. Coding must accurately represent the service that the provider performed, and the patient’s documentation must support the reported codes.
For Medicare chiropractic claims, CPT codes 98940, 98941, and 98942 correspond to chiropractic manipulative treatment based on the spinal regions treated. Make sure the selected code matches the service that the provider actually performed and the documentation that supports it.
Diagnosis coding also matters. CMS guidance for Medicare chiropractic services requires the documentation and claim to support the applicable diagnosis, including the precise level of subluxation when Medicare’s chiropractic coverage rules require that information.
A useful pre-submission question is simple: Does the claim tell the same story as the clinical record?
If the diagnosis, procedure code, date of service, modifier, or other claim information differs from the documentation, the payer may delay, reject, or deny the claim.
What Should Chiropractors Know About the Medicare AT Modifier?
The AT modifier represents an important Medicare-specific consideration for chiropractic billing.
CMS states that providers should use the AT modifier with CPT codes 98940, 98941, and 98942 when they provide active or corrective treatment for acute or chronic spinal subluxation. Providers should not use the modifier for maintenance therapy.
The AT modifier does not establish medical necessity by itself. The practice still must satisfy the applicable Medicare coverage and documentation requirements.
That distinction matters because a modifier cannot substitute for supporting documentation. Before submitting a Medicare chiropractic claim, confirm that the documentation, diagnosis, treatment, and modifier use all support the service that the provider billed.
Can Modifier Errors or NCCI Edits Affect Chiropractic Claims?
Yes. Modifier use must reflect the circumstances of the service and the rules that apply to the payer.
For Medicare, the National Correct Coding Initiative (NCCI) establishes procedure-to-procedure edits that can affect whether providers may report certain services separately. CMS specifically addresses chiropractic manipulative treatment and certain physical medicine and rehabilitation services in its NCCI policy guidance.
Do not add Modifier 59 or another NCCI-associated modifier simply to force payment. CMS identifies circumstances that support separate reporting, such as distinct encounters or appropriate separate anatomic sites, depending on the applicable edit.
The practical lesson is straightforward: do not use a modifier as a workaround when the documentation or coding does not support separate reporting.
How Can Insurance Verification Prevent Chiropractic Claim Denials?
Insurance verification should go beyond confirming that a patient has an active insurance card.
Before treatment begins, staff should verify the information and requirements that apply to the patient’s plan and services. Depending on the payer and benefit plan, that review may include:
- Member and subscriber information
- Active coverage
- Chiropractic benefits
- Copayment, deductible, and coinsurance information
- Visit limits
- Referral requirements
- Prior authorization requirements
- Coverage limitations or exclusions
These requirements vary by payer and plan. Build your verification workflow around the payer and plan involved rather than relying on assumptions from another patient’s coverage.
Document insurance verification calls, including the date of the call, representative information when available, reference numbers, and the coverage information that the representative confirmed. A consistent verification record can make later claim research much easier.
What About Prior Authorization and Credentialing Problems?
Some denials occur before a coding problem ever reaches the payer. Authorization requirements, provider enrollment, credentialing, and benefit limitations can all affect claim processing.
If a payer requires authorization for a service or a specified number of visits, establish a process that tracks the authorization and alerts staff when the practice may need additional authorization.
Monitor provider enrollment and credentialing as well. For Medicare, CMS requires providers and suppliers to periodically revalidate enrollment information. Providers who fail to complete required revalidation can affect their Medicare billing privileges.
Commercial payer credentialing rules vary. Monitor enrollment and contracting status according to each payer’s requirements.
What Should You Do When a Chiropractic Claim Gets Denied?
Start with the actual denial information. Do not assume that the denial reason tells the entire story without examining the claim, documentation, remittance information, and applicable payer policy.
Use a consistent denial workflow:
- Identify the denial reason. Review the EOB, ERA, or other payer notice.
- Determine the root cause. Decide whether the issue involves documentation, coding, eligibility, authorization, coverage, a claim error, or another payer requirement.
- Correct the underlying problem. Submit a corrected claim when appropriate. For other situations, prepare an appeal or provide additional documentation.
- Check the deadline. Follow the payer’s stated correction or appeal timeframe.
- Document the action. Record what your staff changed, submitted, or communicated and when.
- Track the outcome. Keep unresolved denials visible in your accounts-receivable workflow until your team resolves them.
How Long Do You Have to Appeal a Medicare Claim Denial?
For Original Medicare fee-for-service claims, CMS states that providers generally have 120 days from receipt of the initial claim determination to request a redetermination. Submit the request to the Medicare Administrative Contractor (MAC) that made the determination.
Commercial payer deadlines can differ substantially. Check the denial notice, payer contract, provider manual, and applicable plan requirements instead of applying the Medicare deadline to every payer.
Because appeal deadlines can affect your practice’s ability to pursue a denied claim, assign responsibility for each open denial and track the applicable deadline.
How Can a Chiropractic Practice Identify Recurring Denial Problems?
One denied claim may represent an isolated error. Repeated denials involving the same reason code, payer, procedure code, provider, or workflow can point to a larger process problem.
Review denial data regularly and ask these questions:
- Which payers generate the most denials or rejections?
- Which denial reasons occur most often?
- Which claims require correction or resubmission?
- Do documentation problems recur?
- Does your team apply modifiers consistently and appropriately?
- Does your staff track authorization requirements?
- Does your team follow the insurance verification process consistently?
- Does staff use current payer requirements?
- How long does your team take to resolve each denial?
This type of review can turn individual claim problems into useful information about your billing workflow.
What Is the Best Way to Reduce Repeating Chiropractic Claim Denials?
Your practice does not reduce recurring denials simply by submitting more claims. A stronger process starts with accurate information, appropriate documentation, correct coding, payer-specific verification, and consistent follow-up.
For Medicare claims, pay particular attention to current CMS requirements for chiropractic services, including documentation, medical necessity, diagnosis coding, and appropriate use of the AT modifier. For commercial and other payers, verify the rules that apply to the patient’s specific plan.
When denial patterns continue despite internal troubleshooting, outside billing and coding expertise can provide another level of review. HJ Ross Company provides chiropractic billing and coding education and resources, including its Network HotLine, which gives participating practices access to billing and coding expertise.
Need help with chiropractic billing and coding questions? Learn more about HJ Ross Company services, seminars, and billing and coding resources.
Insurance coverage, coding, documentation, authorization, reimbursement, and appeal requirements vary by payer, plan, claim, and patient circumstance. Verify the current requirements that apply to each claim. This article provides educational information and does not constitute individualized billing, legal, financial, or compliance advice.
