Medicare Chiropractic Diagnosis Codes: Choose Wisely! | ChiroTouch
January 25, 2019 by Kathy (KMC) Weidner, MCS-P, CCPC, CCCA Article Insurance, Coding

Many Chiropractors think that diagnosing Medicare patients is one of the simpler things they must do. After all, most Part B Medicare Administrative Contractors (MAC) provide a list of approved diagnosis codes to use. Many even provide guidance on the frequency limitations that they deem appropriate for categories of diagnosis codes. However, as we review and audit chiropractic documentation, we see errors being made on a regular basis. The chiropractic diagnosis codes selected by providers are often non-specific, condition-based or pain-related diagnoses and don’t convey the whole story to the MAC. Why does it matter? Read on…

Primary and Secondary Diagnosis Codes

For most chiropractors, Medicare diagnosis consists of both a primary (subluxation) and a secondary diagnosis for each region of the spine they intend to treat. The secondary diagnosis describes the secondary, neuromusculoskeletal condition relating to each primary subluxation. At least one of the MACs, First Coast Service Options covering Florida, doesn’t require that the primary subluxation diagnosis is included when billing. However, every MAC expects that the documentation will include all the diagnoses and the evidence of how the provider arrived at the diagnostic conclusion.

Consider that the best practice is to correlate each symptom reported by the patient, to findings within your examination, leading to the diagnosis of the primary subluxation and secondary condition that will be addressed in the treatment plan. Therefore, each region of the spine would have a “pair” of chiropractic diagnosis codes for Medicare to consider. This lays the foundation for the medical necessity of your care. When the primary subluxation diagnosis is “paired” with a diagnosis like Cervicalgia or Lumbalgia, it’s leads an auditor to wonder why the patient is being diagnosed with something that they already knew when they walked in your office. And will likely support treatment for only a few visits.

Follow the Road Map

Providers should become familiar with the Chiropractic Local Coverage Determination (LCD) assigned by your MAC jurisdiction. At present, there are 12 MAC jurisdictions, covered by 7 different carriers.  It should be noted that some jurisdictions haven’t provided local guidance for chiropractic in an LCD, and others haven’t clarified which or limited the number of diagnosis codes you may use as secondary. The definitive diagnosing rules, if provided, are laid out for you in the LCD. This essentially provides you with the “cheat sheet” of chiropractic diagnosis codes for Medicare in your area.

An example is found in the Novitas MAC’s LCD. Specific, covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required for the types of diagnoses displayed in each group:

-Twelve (12) chiropractic manipulation treatments for Group A diagnoses

-Eighteen (18) chiropractic manipulation treatments for Group B diagnoses

-Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses

-Thirty (30) chiropractic manipulation treatments for Group D diagnoses

This Novitas LCD imposes frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must also meet all the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, and all Medicare payment rules. When limiting diagnoses are reported, it’s difficult to communicate the patient’s full picture through simple codes. After all, that’s how you report the patient’s story to the MAC.

Tell the Whole Story

Let’s suppose a patient reported with right-sided neck pain, radiating up into the back of the head, causing daily headaches and the inability to turn their head right or left. After a thorough history, we learn that the patient has had chronic neck pain and intermittent headaches for years. Upon further questioning, the patient admitted to bumping their head on a cabinet door in their kitchen a few weeks back. And now they go on to say that the more intense headaches and limited range of motion got worse after the incident. After a complete examination, cervical and upper thoracic subluxations are diagnosed. We determine that due to the chronicity of the problem, the patient’s age, and the incident with the cabinet door, rationale for cervical films is established.

Based on the basic history reported by the patient, depending on the level of decreased function, some providers might be inclined to diagnose cervical segmental dysfunction, cervicalgia, and headache. After all, this was the presenting issue. However, if we review the chiropractic diagnosis code list for Medicare Jurisdiction J, where the provider resides, we find that both cervicalgia and headache fall into the Group A diagnosis list noted above, providing necessity for up to 12 visits. Upon review of the x-rays, the patient clearly has cervical disc degeneration at C6-C7 (M50.323) We find this diagnosis is in the Group D list, potentially allowing for as many as 30 visits, if that were appropriate. This more accurately reports the patient’s presenting condition. When non-specific diagnoses are reported, it short-changes the patient’s ability to have visits covered by Medicare and it incorrectly reports what is really going on.

Complete the Patient’s Story

Accurately describing your patient’s condition using chiropractic diagnosis codes for Medicare is part of your documentation requirement. Using overly-simple, non-descriptive diagnoses attempt to lay the foundation for necessary care is a lose-lose situation. Both the patient and the provider lose because Medicare doesn’t get an accurate picture of their need for care. Resolve to pump up your documentation with better history, stronger examination findings, and accurately reported chiropractic diagnosis codes for Medicare in 2019. Then everybody wins!


About the Author


Kathy Weidner (aka Kathy Mills Chang) is a Certified Medical Compliance Specialist (MCS-P). Certified Chiropractic Professional Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads the largest team of certified specialists in the profession at KMC University and is known as one of our profession’s foremost experts on Medicare, documentation and CA development.

Kathy or any of her team members can be reached at (855) 832-6562 or

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