The Hidden 98940 CPT Code Errors Costing Chiropractors Thousands in Reimbursements
Learn how to bill the 98940 CPT code correctly, avoid claim denials, and understand modifiers, documentation, and Medicare rules.
Chiropractic billing presents its own set of challenges, and one area that befuddles many chiropractic practices is CPT code 98940. Although this code applies to spinal manipulation of one or two levels, there are certain errors that can occur in the documentation, modifiers and diagnosis pairing that can result in denied claims and lost revenue. It’s essential for any chiropractor, billing specialist or claims management team that is dealing with a busy clinic to know the details of this code.
This guide lists every aspect of the CPT 98940 code, including its precise description, how to bill by step, billing mistakes, and Medicare guidelines. At the last, you will have a clear and concise grasp of how to properly bill this code and prevent unnecessary claim rejections.
What Is the 98940 CPT Code in Chiropractic Billing
Chiropractic manipulative treatment for one to two spinal regions is coded as 98940. It is classified as Spinal Manipulation Services. During a chiropractic visit to a patient with limited spinal involvement, this is the code a chiropractor will use. This code is a member of a family of codes that includes 98941 and 98942. Different numbers of spinal regions treated are reflected in each code. The smallest treatment area is in the 98940 CPT code.
98940 is a commonly used CPT code by insurance companies and Medicare for billing. Understanding when to use it and when not to could save your practice from unneeded claim denials. It also allows you to be paid properly for work done.
Documentation Requirements for CPT Code 98940
Accurate reimbursement will be ensured by complete documentation, which will also help to prevent claim denials. Clear clinical documentation that includes the documentation of medical necessity should be included with every claim for CPT Code 98940.
Patient Evaluation: Record the patient’s symptoms, medical history and why they went to a chiropractor. Specify the affected area of the spine and the implications for functioning.
Diagnosis Codes: Using the right ICD 10 codes to support the chiropractic adjustment. The diagnosis should be consistent with the patient’s record of the patient’s condition and the treatment delivered.
Spinal Region Treated: The term “Spinal Region Treated” only applies to CPT Code 98940 when the chiropractor treats 1 to 2 spinal regions. Identify each spinal area treated during the visit, for accurate coding.
Treatment Details: Outline the chiropractic manipulative treatment that was provided. Add the adjustment technique, areas of adjustment and the patient’s reaction to the treatment.
Medical necessity: Give the reason why the chiropractic adjustment was needed. Record the beneficial results of treatment based on the patient’s condition in terms of relieving pain, improving function or restoring mobility.
Provider Signature: Fill in all records with the signature and date of the provider treating the service. Claim(s) may be denied if there is no documentation or documentation is incomplete during payer review.
Who Can Bill the 98940 CPT Code for Patient Visits
Licensed chiropractors are the primary providers who bill the 98940 CPT code. This code would be considered in the scope of chiropractic practice. This is not the code that is typically used by other health care providers. There are some multidisciplinary clinics that hire chiropractors with physical therapists or medical doctors. In these practices, the chiropractor alone is allowed to use 98940 CPT code. This code should only be used when the type of provider must be verified prior to the submission of any claim by the billing staff.
Additionally, it is essential that the treatment provider is appropriately credentialed with the insurance provider. Claims that are submitted without proper credentialing may be denied automatically for the CPT code 98940. This is a critical step in successfully securing reimbursement, often overlooked.
Key Differences Between 98940, 98941, and 98942 CPT Codes
Choosing the correct code depends entirely on how many spinal regions were treated during the visit. The table below makes the comparison simple.
| CPT Code | Spinal Regions Treated | Common Use Case |
|---|---|---|
| 98940 | One to two regions | Minor spinal involvement |
| 98941 | Three to four regions | Moderate spinal involvement |
| 98942 | Five regions | Full spine treatment |
Always match the code to the actual number of regions treated that day. Do not assume the same code applies to every visit for a returning patient. Treatment plans change, and so should the code reflecting that change.
Common Diagnosis Codes That Support 98940 Claims
Diagnosis codes play a major role in justifying the use of the 98940 CPT code. The table below highlights commonly paired diagnoses.
| Diagnosis | ICD-10 Category | Why It Supports 98940 |
|---|---|---|
| Cervicalgia | Neck pain related codes | Matches cervical region treatment |
| Lumbago | Low back pain codes | Matches lumbar region treatment |
| Thoracic spine pain | Mid back pain codes | Matches thoracic region treatment |
| Segmental dysfunction | Spinal dysfunction codes | Directly supports manipulation |
The diagnosis should clearly connect to the spinal regions mentioned in the treatment notes. Mismatched diagnosis and treatment codes are a frequent reason for claim rejections. Billing teams should double check that the diagnosis supports medical necessity for the 98940 CPT code.
Step-by-Step Guide to Billing 98940 CPT Code Correctly
Verify regions treated: List specific regions treated during patient visit. This will help decide if the selected CPT code 98940 is the appropriate code.
Match documentation: Give clinical notes that describe the areas of manipulation and the technique used. The documentation is unclear, which causes issues when reviewing insurance.
Select diagnosis code: Select the appropriate diagnosis code to support the treatment administered, and to relate logically to the regions treated.
Submit the claim: Submit claim using 98940 CPT code with any modifiers (e.g., AT for Medicare).
Before you send: Double check everything before sending to the payer to prevent small mistakes.
Monitor and follow-up: Keep on track and follow up on claim status and follow up on delayed claims, as it is important to protect revenue.
Modifiers Commonly Used With the 98940 CPT Code
Modifiers clarify the specific circumstances surrounding a billed service. The table below summarizes the most relevant one.
| Modifier | Purpose | Payer Relevance |
|---|---|---|
| AT | Indicates active treatment, not maintenance care | Required by Medicare for 98940 claims |
| GA | Shows a waiver of liability is on file for the patient | Used when payment denial is expected |
| GY | Indicates the service is statutorily excluded from coverage | Helps with accurate claim categorization |
| GZ | Shows the service is expected to be denied as not reasonable | Used for informational billing purposes |
| 59 | Identifies a distinct procedural service on the same day | Applied when billing alongside other procedures |
| 25 | Marks a significant, separately identifiable evaluation service | Used when an exam is billed with the 98940 CPT code |
Always check payer-specific guidelines before attaching modifiers to the 98940 CPT code, since incorrect use is a common reason claims get rejected.
Reimbursement Rates and Insurance Coverage for 98940
The 98940 CPT code reimbursement rates will differ from insurance company to insurance company and from place to place. This code usually gets reimbursed by Medicare at a specific “national” rate and is adjusted by area to account for local cost factors. The same code can be used at two chiropractic offices in the same city, but may pay differently in each office. Coverage is also a matter of insurance policies and packages of the patient.
Certain plans place a maximum number of chiropractic visits that will be covered during a year, while other plans will cap chiropractic visits by dollar amount. Others are more likely to need authorization prior to approving claims for spinal manipulation treatment, putting an additional layer in the billing process. Whenever possible, practices should ensure patients are aware of the benefits of their treatment before it commences. This helps avoid any surprises in terms of denials and helps establish fair expectations with patients in regard to their out-of-pocket expenses.
This is because all concerned find the entire billing process easier, knowing the details of coverage beforehand. It also aids in maintaining a history of payer-specific reimbursements over time. There are some clinics that will show a mean payment amount per insurer for 98940 CPT Code. This information can help the practice determine which payers are inconsistent in their reimbursement or prone to underpayments, and allow the practice to act in advance of the situation.
Medicare and Medicaid Guidelines for 98940 CPT Code Billing
There are strict guidelines for Medicare on use of the 98940 CPT code. It only applies to the manual correction of subluxation. Improvement in the patient’s condition must be objectively demonstrated before continuing treatment. There are national Medicaid guidelines that differ by state. In some states, chiropractic care is well covered, and in others, it is either scantily covered or not covered at all. Be sure to verify the Medicaid policy in your state before using the CPT 98940 code.
Extensive documentation is needed to support medical necessity for both Medicare and Medicaid. A major reason for claims being denied is because of missing or incomplete records. You will be able to keep your practice in compliance and properly reimbursed by keeping abreast of policy changes.
Common Billing Errors and How to Avoid Claim Denials
98940 CPT Code is frequently incorrectly coded and this can result in claim denials, payment delays, and administrative burdens. Many of these issues can be prevented if submitted claims are accurately documented, the correct code is selected and thorough claim reviews are conducted.
Billed for Incorrect Number of Spinal Regions: 98940 CPT Code should be used only if the chiropractor works on one or two areas of the spine. This code can be used for treatment in 3 or more regions and claim denial or incorrect reimbursement may result.
Missing Medical Necessity: For each claim, it is essential that the chiropractic adjustment is fully explained as to its medical necessity. Include the patient’s symptoms, examination findings, diagnosis and functional limitations to show the need for treatment.
Incorrect ICD 10 Diagnosis Codes: Always choose ICD 10 diagnosis codes that reflect the patient’s condition and in relation to chiropractic manipulative treatment. There should be no mismatch between diagnosis codes and clinical documentation, or there will be questions from payers or claim rejections.
Missing Required Modifiers: There are several modifiers which many insurance payers will require for chiropractic services. For instance, Medicare normally needs Modifier AT for active therapy. Not providing a required modifier can postpone processing or lead to claims being denied.
Incomplete Documentation: The clinical notes should indicate the areas of the spine treated, the manipulation technique used, examination findings and the provider’s signature. Full documentation will document that the billed service is provided correctly.
How to Appeal Denied Claims Involving the 98940 CPT Code
First, read carefully the reason for the denial to learn what was wrong. A significant number of denials are due to something as simple as a documentation coding error that doesn’t require much in the way of additional effort or change. Collect evidence in support of treatment that creates clearly defined medical necessity. This could contain progress notes, previous imaging or changed treatments based on the patient’s condition. Compose an appeal letter that is clear, factual and explains why the claim was denied (if applicable, include the payer policy number). Make sure the appeal is submitted within the timeframe required of the payer otherwise the claim may be lost.
Maintain a log of all appeals in the future. Being able to monitor trends in denials can help you mitigate the risk of future denials, particularly if the same kind of claim keeps being denied by the same payer. A proactive appeals strategy will help maintain your practice’s income in the long run and alleviate the burden of your billing staff. Many payers have a higher level review process if the appeal is denied a second time. This is a good consideration when there is adequate documentation of the medical necessity for the 98940 CPT code. Sometimes, it really is all about persistence, particularly if the denial was due to some minor technical problem and not a coverage problem.
Why Choose Billing Care Solutions for Chiropractic Billing?
Billing Care Solutions is aware of the challenges that chiropractors experience on a daily basis. We are experts in accurate coding, which includes correct use of the 98940 CPT code. We consistently help practices minimize denials and maximize cash flow. Medicare, Medicaid and private payer guidelines are kept up to date at all times. This translates to a first time submission of claims that is right. The fewer the errors, the sooner you’ll get paid for your practice. Our billing professionals are knowledgeable in documentation review, coding accuracy and claim follow-up. You can concentrate on treating the patient, and we can take care of the financial paperwork. Collaborate with Billing Care Solutions and enjoy hassle-free, effective chiropractic billing today.
Conclusion
Billing the diagnosis of 98940 is a process that requires attention to detail, but isn’t overwhelming. So, if you know what the documentation requirements are, it’s a much easier process to manage. Inspection of eligibility and double checking of diagnosis codes are just a few examples of the little things that add up when it comes to reducing denials. Since chiropractic practices that spend time on accurate coding generally have fewer claims that are rejected and faster claims payments, they will have improved business outcomes.
Once you understand exactly when and how to use the 98940 CPT code, it’s easy to master. Most of the common billing pitfalls can be avoided by maintaining excellent documentation and applying the modifiers correctly. Support is available for those who find all this too much on top of a busy practice. Billing Care Solutions is here to help your team with the 98940 CPT code and all aspects of your billing process with confidence.
