Where 30 Percent of Chiropractic Medicare Payments Go Wrong

by | Dec 1, 2025 | Compliance & Risk

chiro medicare documentation

The federal improper-payment data for chiropractic is unflattering and widely misread. Almost none of it is about clinical judgment. Nearly all of it is about the chart.

Key Takeaways

  1. CMS’s 2025 CERT data put the improper payment rate for chiropractic services at 30.4 percent, representing about $144 million – down from 39.3 percent in 2023 but still far above most specialties.
  2. 89.5 percent of those improper-payment dollars trace to insufficient documentation. Only 3 percent involve medical necessity. The exposure is chart quality, not clinical decision-making.
  3. The AT modifier signals active treatment, not medical necessity. CMS states plainly that its presence does not by itself establish that a service was reasonable and necessary.
  4. Medicare covers exactly three chiropractic codes – 98940, 98941, and 98942. Extraspinal manipulation (98943) is not covered, and all other services a chiropractor furnishes or orders fall outside the benefit.

Chiropractic has carried an uncomfortable statistic for two decades, and it is worth stating precisely rather than defensively. CMS’s Comprehensive Error Rate Testing program put the improper payment rate for chiropractic services at 30.4 percent for 2025 – roughly $144 million. That is an improvement from 33.6 percent in 2024 and 39.3 percent in 2023, and a substantial one from the 41 percent reported in 2018. It is still several times the rate of most physician specialties.

Now the part that almost never gets quoted alongside it. Of those improper-payment dollars, 89.5 percent are classified as insufficient documentation. Medical necessity accounts for 3 percent. Incorrect coding accounts for 1.5 percent. In other words, the federal data does not say that chiropractors are providing unnecessary care and getting caught. It says the chart did not prove what the claim asserted. That is a solvable, operational problem, and it is solvable without changing a single clinical decision.

What Medicare Actually Covers

The benefit is narrower than many practices operate as though it is. By statute, Medicare recognizes chiropractors as physicians only with respect to treatment by means of manual manipulation of the spine to correct a subluxation. CMS’s Benefit Policy Manual states that all other services furnished or ordered by chiropractors are not covered. Practically, that means three billable codes: 98940 for one to two spinal regions, 98941 for three to four, and 98942 for five. Extraspinal manipulation – 98943 – carries a non-covered payment status. Exams, x-rays, therapies, and modalities performed by the chiropractor are outside the benefit even when clinically appropriate, and the ABN conversation with the patient needs to happen before the service, not after the denial.

The AT Modifier Is Widely Misunderstood

Here is the language that matters, from the Benefit Policy Manual: “The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied.” And then, in the same section: “However the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, contractors may deny if appropriate after medical review.”

Read those two sentences together. The AT modifier is a switch that distinguishes active treatment from maintenance care. It is not an attestation of medical necessity and it confers no protection. The OIG made this point directly in 2009, finding that the modifier “did not prevent inappropriate payments for maintenance therapy because chiropractors continued to submit claims for maintenance therapy with the AT modifier.” A practice that applies AT to every claim as a matter of template default has not solved anything; it has created a pattern that is trivially easy to spot in claims data.

Nine of every ten improper-payment dollars in chiropractic are documentation failures, not clinical ones. The care was probably fine. The chart could not prove it.

What the Chart Has to Show

The requirements are not mysterious, and the failures are repetitive. The initial visit needs a documented history, the presenting symptoms, a description of the subluxation with the level identified, and a treatment plan with measurable goals and an expected duration. Subsequent visits need documented change – what has improved, what has not, what the objective findings show now, and how that supports continuing active treatment toward the stated goal. The date of the initial treatment and the treatment plan need to be traceable from any visit note. And the note must show that manual manipulation of the spine was performed and at which levels.

The most common failures we find in chart audits:

  • Cloned notes. Visit fourteen reads identically to visit three. Nothing in the record demonstrates the functional improvement that justifies continued active treatment – which is exactly the evidence a reviewer is looking for.
  • Goals that are not measurable. “Reduce pain, improve function” is not a treatment plan. A reviewer cannot assess progress against it, so there is no progress in the record.
  • Missing initial treatment date on subsequent claims. A pure clerical defect that produces denials on entirely appropriate care.
  • Region count that does not match the note. 98941 billed where the note documents manipulation of two regions. This is the coding failure the CERT data assigns to the small incorrect-coding bucket, and it is completely preventable.
  • No documented re-evaluation. Care that runs past the initial plan duration without a documented reassessment reads as maintenance regardless of what the AT modifier says.

Volume Is Not Itself a Problem, But It Is a Signal

The OIG’s foundational 2005 report observed that as chiropractic care extends beyond twelve treatments in a year it becomes increasingly likely that individual services are medically unnecessary, and that the likelihood increases significantly after twenty-four. A later OIG audit found that $358.8 million of $438.1 million in chiropractic payments examined – about 82 percent – was unallowable, and floated the idea of a hard annual cap. CMS has not adopted a cap, and a 2015 OIG recommendation for a more reliable control on identifying active treatment was closed as unimplemented in 2024.

Two practical conclusions. First, no cap exists, so long courses of care remain payable when the documentation supports active treatment – but the record has to carry the weight, because the volume itself will draw attention. Second, that same 2015 OIG work found just 2 percent of chiropractors accounted for half of questionable payments, which is a reminder that the profession’s aggregate error rate is driven by a small tail. Being unremarkable in the claims data is a defensible strategy.

From the Field

A four-doctor chiropractic group in the Northeast received a records request covering forty Medicare dates of service. The initial internal read was that the care was clearly appropriate, and it was – but the notes could not demonstrate it. Visit documentation was largely cloned, treatment plan goals were unmeasurable, and the AT modifier had been applied by EHR default on every claim including several that were plainly maintenance care. The engagement started with a hundred-chart audit against the actual manual language, then rebuilt the note templates so that documented functional change was a required field rather than an optional one. Rather than deliver a compliance manual, our fractional COO worked through six weeks of chart review sitting with each doctor on their own notes, and the practice’s front-end process was changed so maintenance visits were flagged and an ABN executed before the visit. The response to the records request was submitted with a supportable position on the majority of dates, and the practice’s subsequent internal audit scores went from failing on roughly a third of charts to passing on more than ninety percent.

Build the Internal Audit Before Someone Else Does

Every chiropractic practice billing Medicare should be auditing its own charts on a schedule – ten charts per provider per quarter, scored against the manual requirements, with results reviewed by name and findings routed back to the provider who generated them. That single habit is what separates practices that respond calmly to a records request from practices that discover their exposure while under a deadline. It costs a few hours a quarter and it is the cheapest insurance in the building.

Documentation improvement also fails in a specific and predictable way: the practice buys a compliance manual, everyone agrees the notes should be better, and nothing changes because improving documentation requires changing what providers do at the moment of charting. A consultant can deliver the audit, the gap analysis, and the rewritten templates, and if you have a compliance-minded office manager who will hold providers to them, that may be exactly the right scope of work.

If the person who would enforce it is you – and you are also the highest-volume provider – the enforcement will not happen, because you cannot audit yourself into a habit. That is where fractional executive support earns its keep: someone who sits with each doctor on their own charts, rebuilds the templates inside your EHR, and runs the quarterly audit until it is a habit rather than an initiative. Ask any firm you are considering whether that is what they do, or whether they deliver a binder. Both have their place; only one changes the notes.

Sources

  1. CMS, 2025 Medicare Fee-for-Service Supplemental Improper Payment Data — https://www.cms.gov/files/document/nov-2025-medicare-ffs-supplemental-improper-payment-data-2025922.pdf
  2. CMS, Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15 — https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
  3. HHS Office of Inspector General, OEI-09-02-00530, Chiropractic Services in the Medicare Program — https://oig.hhs.gov/documents/evaluation/2305/OEI-09-02-00530-Complete%20Report.pdf
  4. HHS Office of Inspector General, OEI-07-07-00390, Inappropriate Medicare Payments for Chiropractic Services — https://oig.hhs.gov/oei/reports/oei-07-07-00390.pdf
  5. HHS Office of Inspector General, A-09-14-02033, Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare Requirements — https://oig.hhs.gov/oas/reports/region9/91402033.pdf
  6. CMS, MLN Matters SE1601, Chiropractic Services – Medicare Coverage — https://www.cms.gov/files/document/se1601.pdf

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