Optimizing Chiropractic Billing: Best Practices for a Smoother Revenue Cycle

Chiropractic billing presents challenges due to changing regulations, evolving codes, and the need for constant efforts to secure reimbursements.

Effective billing in is crucial for maintaining financial health and ensuring the sustainability of chiropractic practices. However, chiropractic billing comes with a unique set of challenges such as stricter documentation standards, limited Medicare coverage, and complex and evolving coding requirements. Chiropractic services have also faced growing scrutiny for fraudulent billing practices. Relying on professional chiropractic billing services offers a practical way to overcome these challenges and ensure clean claim submission for optimal reimbursement. This blog discusses best practices for optimizing the chiropractic billing process.

Challenges of Chiropractic Billing

While healthcare billing is complex, chiropractic billing has its own unique challenges:

● Stricter documentation standards: Insurers and CMS require detailed records to establish medical necessity for services like spinal manipulation. Incomplete documentation can lead to claim denials or audits.

● Limited Medicare coverage: Medicare reimburses only for chiropractic services related to spinal subluxation, requiring precise diagnosis and treatment codes. Each visit must demonstrate medical necessity, even though there’s no annual cap on adjustments.

● Complex coding requirements: Chiropractors must use various codes for adjustments, therapeutic exercises, and modalities. Accurate documentation is essential to avoid coding errors and claim rejections.

● Higher claim scrutiny: Chiropractic care is often flagged for overutilization by insurers, leading to more audits and rejections than in other specialties.

With so many components to manage, chiropractic billing requires careful attention to detail to avoid errors.

Chiropractic Billing Steps and Best Practices

Similar to billing for other specialties, billing for chiropractic services has several steps from patient appointment scheduling and insurance verification to coding and claim submission. Effective billing involves best practices to ensure smooth operations and minimize errors. Here’s a streamlined approach:

1. Collecting Accurate Patient Information

Before the treatment begins, all relevant patient details are collected. This includes demographic information and insurance details like the payer name, policy number, and coverage. Information is also collected on pre-existing conditions or prior treatments that could affect chiropractic care. Accurate patient information helps avoid delays and denials during the billing process.

2. Insurance Verification and Authorization

This involves verifying the patient's insurance coverage before starting treatment to confirm that the patient’s insurance is active and understand the extent of chiropractic care covered, including the number of visits, co-pays, and any limitations.

Insurance verification specialists will also check if the insurance company requires prior authorization for specific chiropractic services. Prior auth requirements can vary. For instance, starting September 1, 2024, UHC/Optum requires prior authorization for Medicare-covered chiropractic services (billed with the AT modifier) provided in office and outpatient hospital settings, excluding home services. Prior authorization is not necessary for claims related to the initial evaluation, but is required for the treatment plan, which outlines the number of visits.

Verifying patient coverage minimizes unexpected denials or underpayments due to eligibility issues.

3. Proper Documentation of Services Rendered

For optimal reimbursement, claims should be supported by accurate documentation of services rendered. By providing comprehensive records that clearly justify the treatments given, chiropractors can demonstrate compliance with insurance requirements and defend against potential claims denials. Chiropractors must clearly document:

o The type of service provided (e.g., spinal manipulation, physical therapy), using appropriate ICD-10 codes to indicate the diagnosed conditions being treated.

o Treatment plans with details on the number of sessions, type of procedures, and expected outcomes, as well as notes on the patient’s progress and any adjustments made.

Thorough documentation of medical necessity not only ensures proper billing but also protects the practice in the case of audits.

4. Accurate Coding

Accurate coding is key for successful chiropractic billing and reimbursement. Chiropractors must use the correct ICD-10 codes to describe the patient's diagnosis and condition and CPT codes for the procedures or services provided, such as spinal manipulations or physical therapy. Any additional services or equipment provided, such as durable medical equipment (DME) should be reported using proper HCPCS codes.

Using accurate codes helps reduce claim rejections or underpayments. This requires staying on top of code updates. For instance, in 2024, lumbar and lumbosacral disc degeneration codes are updated to five characters, offering greater specificity. These revised codes now differentiate between discogenic back pain only, leg pain only, a combination of back and leg pain, or cases where no pain is mentioned. Additionally, a new code has been introduced for dysfunction of the multifidus muscles in the lumbar spine, along with enhanced codes for more precise classification of tenosynovitis.

Staying up to date can prevent billing with incorrect chiropractic CPT and ICD codes that can lead to claim rejections and delays in payments.

5. Submit the Claim

Once the codes are assigned, the claim, along with the documentation, is submitted to the patient's insurance provider. All claims should be submitted promptly, as delayed submissions can result in missed reimbursement opportunities.

6. Patient Billing

If there are any remaining balances after insurance payment, the chiropractic office bills the patient for those amounts. This may include co-pays, deductibles, or services not covered by insurance.

7. Follow-Up

Finally, the billing team follows up on any outstanding payments, whether from insurance or the patient. This includes regular checks to see if the claim is processed or if any issues arise. If a claim is denied, the team promptly follow up with the insurance provider to understand the reason and submit necessary documentation to resolve the issue. In case of a denial, they will file an appeal with the necessary supporting documentation to overturn the decision.

Even minor errors in the above processes can lead to significant billing issues. For example, an Office of Inspector General (OIG) audit revealed that approximately $358.8 million—82% of the $438.1 million Medicare paid for chiropractic services—was deemed unnecessary (dmagazine.com).

Expertise Matters

Optimizing chiropractic billing is essential for ensuring a smoother revenue cycle and maintaining the financial health of your practice. By implementing best practices such as accurate documentation, efficient coding, proactive insurance verification, and regular claim follow-ups, chiropractors can significantly reduce denials and improve reimbursement. However, the complexity of chiropractic billing—marked by strict documentation requirements, Medicare limitations, and high scrutiny—can be overwhelming to manage in-house.

Partnering with professional chiropractic billing services provides a reliable solution to streamline the process. These services bring expertise and technology to ensure clean claims, reduce errors, and enhance revenue. By focusing on patient care and entrusting billing to specialists, chiropractic practices can improve their revenue cycle and boost operational efficiency.