Modifiers are a necessary part of billing for chiropractic services. Chiropractic billing modifiers are used with CPT codes for chiropractic to demonstrate the unique factors of a given procedure or service.

If a CPT code requires a modifier but is billed without one, it will be rejected by the insurance payers with justification on the ERA/EOB stating the reason as clubbing with another service or billed the same day. Even if you ask the insurance company, they won’t tell you what chiropractic codes and modifiers chiropractors should use.

In simpler terms, the insurance company won’t guide you on how to get your claim paid by telling you which modifiers to use. There are many chiropractic billing modifiers, but these 5 modifiers for chiropractic billing are most commonly used in the chiropractic clinics and required on a claim.

Why Do We Need Modifiers for Chiropractic Billing?

• Modifiers play a crucial role in identifying particular chiropractic CPT codes, preventing them from being bundled with other services and billed on the same day.
• They accompany CPT codes for chiropractic and signal to insurance companies that there’s a distinct aspect to the billed services.
• Using modifiers can lead to higher reimbursements.
• If a required modifier is omitted from chiropractic CPT codes, claims could be rejected.
• Chiropractic modifier codes also aid in comprehending specific guidelines set by payers.

Common Modifiers Used in Chiropractic Medical Billing 

1. Modifier 59

Distinct Procedural Service

Modifier 59 is one of top used modifiers for chiropractic billing. This modifier is used to distinguish an important, recognizable non-E/M service that was performed by the same provider on the same day. Under certain circumstances, it may be necessary for a provider to report that a procedure or service was performed independently from other non-E/M services. So the claim should show it as a separate service.

For example, Chiropractic Adjustment CPT codes (98940-42) and Manual Therapy code (97140)should not be performed in the same area and a provider must mention Modifier 59 to indicate that they are separately payable.

Note that when you mention modifier 59 with a CPT code in the HCFA claim form, provide supporting documentation that a different session, different procedure, or different site was performed on the same day by the same individual.

In January 2015, the Centers for Medicare and Medicaid Services (CMS) published subsets of the 59-modifier. There are four subsets of Medicare modifiers for chiropractic billing can be used instead of the 59-modifier:

• XE Separate Encounter: This subset is relevant to use when a provider wants to indicate that a service is distinct because it occurred during a separate encounter.
• XS Separate Encounter: This subset is relevant to use when a provider wants to indicate that a service is distinct because it was performed on a separate structure.
• XP Separate Encounter: This subset is relevant to use when a provider wants to indicate that a service is distinct because it was performed by a different practitioner
• XU Unusual Non-Overlapping Service: This subset is relevant to use when a provider wants to indicate that a service is distinct because it does not overlap the usual components of the main service.

Documentation: Documentation should provide evidence of distinct sessions, procedures, surgeries, sites or organ systems, incisions or excisions, lesions, or injuries (or areas of injury in extensive cases) that are not typically addressed or conducted by the same individual on the same day.

2. Modifier 25

Significant, Separately Identifiable Evaluation and Management Service by the Same Provider or Other Qualified Healthcare Professional on the Same Day of the Procedure or Other Service.

This is one of the most common chiropractic modifiers. This modifier is exclusively used for evaluation and management codes when billed in conjunction with treatment. Modifier 25 indicates that the provider performed an exam that qualifies as significantly separate from any other services rendered that day. Similar to modifier 59, detailed documentation is key to supporting the decision-making involved during the course of the treatment.

Modifier 25 may be appended only to E/M service codes within the range of chiropractic CPT codes — 99201-99499. Note that if you were billing an evaluation (EM code) with a manipulation (CMT code) on the same date of service, you must use the 25-modifier with the manual therapies in order to get the claim paid by the insurance company. Some insurance companies might deny claims that include an EM and a CMT code on the same day, but providers can appeal it with proper documentation and get it corrected.

Documentation: Report chiropractic modifier 25 only when accompanied by documentation of the E/M service, showing its significance separate from another service provided on the same date, and independently supporting the reported level of services.

3. AT Modifier

The Active Treatment Modifier. This can be acute, chronic, or exacerbation of a chronic condition.

The AT chiropractic modifier was developed to define the difference between active treatment and maintenance treatment. The AT modifier is appended to the chiropractic manipulative treatment (CMT) code. When AT modifier is added to CMT codes, it indicates that the care is deemed “medically necessary.”

When dealing with chiropractic services under Medicare coverage, it’s crucial for chiropractors to use the appropriate AT modifier on a claim when delivering active/corrective treatment for acute or chronic subluxation. However, it’s important to remember that the inclusion of the AT modifier doesn’t automatically confirm the service’s medical necessity. Medicare maintains the authority to deny claims if deemed suitable following a thorough review.

Documentation: Again documentation is the key when it comes to using AT modifiers for chiropractic services in Medicare claims. The document should include detailed information on an active episode of care and outline the treatment’s effectiveness throughout the treatment period. The document must include:

• History of the present concern for each area of the spine
•  Objective examination findings
• Diagnosis for each region to be treated
• A treatment plan that includes frequency, duration, goals, and how the care will be evaluated for effectiveness.

Note that Medicare pays only for active treatment to correct acute or chronic subluxation. Medicare does not pay for maintenance therapy.

4. GA Modifier:  Providers who have got Advance Beneficiary Notification (ABN) signed by the beneficiary can use the GA modifier with “covered but not payable procedures” which is only 98940-98942. This is the modifier you would append to the procedure codes when the patient has transitioned to maintenance care.

5. GY Modifier: Added to all services except the CMT for Medicare claims. The GY modifier indicates that the service is “statutorily excluded from Medicare benefits”. This modifier is used with all other services rendered in your practice, such as X-rays, exams, tests, etc. Note that Medicare will not reimburse for these non-covered services when provided by a chiropractic provider, but you must code correctly.

One of the frequently used modifiers in chiropractic billing is -52. Think of this modifier as a way to show that a doctor decided to do less or skip part of a service or procedure. It’s often used when a service doesn’t take as long as it usually should, but the doctor still did it. The -52 modifier is officially called “Reduced Services.” Sometimes, a doctor might choose to do less of a service, and when this happens, the code for the regular service gets the -52 added to it. This helps show that the service was reduced, without changing the basic service code.

Note: Do not use GY on maintenance care spinal CMT. Examples: 99202-GY-25 and 72100-GY.

Important Notes on Medicare Modifiers for Chiropractic Billing

GA Modifier: This is one of modifiers used in chiropractic billing that indicates if an Advanced Beneficiary Notice (ABN) is on file, allowing the provider to bill the patient if the service is not covered by Medicare.

GY Modifier: Applied to all services except Chiropractic Manipulative Treatment (CMT) for Medicare claims, as services other than Chiropractic Adjustment are not covered by the Medicare Program when provided by a chiropractor.

Conclusion

Chiropractic modifiers are crucial in chiropractic medical billing. A proper understanding of the most common chiropractic modifier codes and how and when to utilize them can escalate the reimbursement process. At zHealth, we make it easy to code correctly, submit claims on time, and get those denied claims paid. Our managed billing services help you save thousands of dollars each month in both time and money. Our revenue cycle management services for chiropractic practices include revieiwing chiropractic CPT codes and modifiers, submitting claims and tracking claim status, following up on A/R, and managing appeals & denials, and reporting. zHealth’s expert billers and coders can handle all your chiropractic medical billing needs and claim settlements. For more information, call us at +1 (800) 674-2908.