9 Chiropractic Coding and Billing Red Flags - Chirotouch
October 5, 2022 by ChiroTouch Team Article Billing, Coding


  • The CMS has introduced more stringent regulations for chiropractic billing and coding, which could result in chiropractors having to repay CMS in instances of overpayment.
  • Common causes of overpayment include a failure to demonstrate medical necessity, the use of incorrect billing codes, a lack of documentation, and improper upcoding or downcoding, among others.
  • Having a centralized view of customer data, insurance, and provider notes and documentation can reduce the potential for chiropractic billing errors.

Are your chiropractic billing processes as reliable and accurate as you think they are? It’s imperative to be certain. The Centers for Medicare and Medicaid Services (CMS) has implemented more stringent regulations to ensure healthcare providers are getting reimbursed fairly. As a result, CMS may identify cases of “potential overpayment” based on claims data.

To avoid being audited and having to pay back improperly billed services, it is crucial for chiropractors to be aware of red flags for coding and billing so that they can manage their practice accordingly.

Here’s what to look for.

1. Failure to Demonstrate Medical Necessity

Medical necessity is one of the most important elements for any insurance claim. Chiropractors must prove that their treatments were medically necessary to the patient in order to receive reimbursement.

One way to do this is to support any procedures with clearly written SOAP notes. Also, Medicare expects providers to bill multiple CPT codes for multiple procedures. Don’t file everything under one code. Be as specific as possible when using codes so payers can understand exactly what services were rendered and how they were relevant to each patient’s condition.

2. Using an Incorrect Code

Chiropractic billing and coding is its own language. Codes are constantly being updated, too. Keep your billing staff ahead of the curve by investing in ongoing education about code updates. Use chiropractic billing software that automatically updates with code changes and integrates charting and billing for automated data flow.

3. Lack of Independent Documentation

working with a patient

Independent documentation refers to any documentation (such as SOAP notes) that isn’t required as part of a claim but could help support its validity. It’s the what and the why behind the treatment’s medical necessity. Not being able to support your reason for providing a service to a patient could be a red flag to payers.

4. Bundled Services with Independent Documented Services

Bundled services are those that combine several services as part of a single treatment. They complement each other and need to be performed together on the same visit. As a result, these services are billed together (in a bundle) instead of being billed and reimbursed separately.

In many cases, you must bill for services separately, even though they may be considered bundled. A modifier added to a code designates that a service was performed above and beyond the normal requirements.

One example is to separate an exam and the treatment performed on the same day using the -25 modifier. This tells the payer that the exam was performed beyond the normal evaluation included in the treatment codes.

5. Unbundling of Services

Likewise, unbundling certain services that should be considered bundled could be cause for review. To “unbundle,” the purpose of each service must stand alone as distinct. Otherwise, it might not be eligible for separate reimbursement.

Hot packs are an example of this; some payers no longer offer separate reimbursements for them. Some payers also bundle mechanical traction with spinal manipulation; therefore, they can’t be billed separately.

6. Excessive and/or Improper Upcoding

Upcoding refers to medical bill codes that reflect a more serious illness or condition than a patient actually experiences or a more expensive treatment than the patient received. Both are examples of a false claim and can carry serious consequences.

If a provider habitually upcodes, it could constitute fraud and expose you to legal proceedings. Thorough patient documentation can help combat the potential risk of upcoding.

7. Multiple Procedures per Visit

working on a patient's back

It’s common for chiropractors to use a range of modalities to improve patient care. However, offering too many therapies in a single visit may be considered excessive by some payers and not necessary.

An example of this is having too many passive therapies, such as hot or cold packs, electrical stimulation, and therapeutic exercises. Not having enough active therapies (such as spinal manipulation) with the passive therapies can be a red flag for payers. Too many similar passive therapies during the same visit can also seem unnecessary.

8. Excessive Use of the Same Diagnosis Codes for Every Patient

It’s not surprising that many of your patients will come to you with similar needs and conditions. However, making one-size-fits-all diagnoses for every patient can be a red flag to payers. Even with similar symptoms and complaints, patients should have a custom plan of care that caters to their needs and diagnoses. These plans should not be identical to another patient’s plan.

Customizing your notes and treatments and providing plenty of detail ensure you’re billing for each patient on an individual basis.

9. Prolonged Duration of Treatment

It’s natural (and desirable) for patients’ conditions to improve as they continue their chiropractic care. It’s also advisable for patients to continue with maintenance care once their initial condition improves and they no longer require the same treatment intensity and frequency.

However, it’s a red flag when patients continue with the same treatment months after their initial injury or complaint. This may be considered excessive medical care and may require changes in how you code and bill.

How ChiroTouch Creates Confidence in Chiropractic Billing

Chiropractors can prevent red flags in chiropractic billing with proper documentation and purpose-built billing software. ChiroTouch, the standard in chiropractic EHR, offers completely integrated scheduling, charting, and billing, making documentation easy and accurate.

ChiroTouch Advanced handles the full claims cycle management process, enabling electronic claims submissions and automatic status updates. Add CT MaxClear to manage all claims in a single place and achieve a 98.06% payer acceptance rate. Our completely integrated solution supports you every step of the way, eliminating the need for multiple systems and vendors.

See how ChiroTouch helps you improve your chiropractic billing when you book a demo.


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