By Cyber Sense Billing Team · Published · Updated
The basic rule: manipulation includes a pre-manipulation assessment
Chiropractic manipulative treatment codes 98940–98942 include a pre-manipulation patient assessment. That means the routine evaluation a chiropractor performs before each adjustment, checking the patient's status and the treated regions, is already part of the manipulation code. An E/M code should not be added for that routine work. This is one of the most common reasons chiropractic E/M claims are denied or later recouped.
A separate E/M service may be reported only when the chiropractor performs a significant, separately identifiable evaluation beyond the usual pre-manipulation assessment, and documentation shows it.
What a separately identifiable E/M looks like
Situations that may support a separate E/M include the initial evaluation of a new patient, a formal re-evaluation at a planned interval, evaluation of a new injury or new complaint, or a significant change in the patient's condition that requires reassessment and a change in the treatment plan. The note should show the reason for the evaluation, history and examination appropriate to the problem, the clinical assessment, and the resulting plan. On the claim, modifier 25 is appended to the E/M code when it is billed on the same day as manipulation.
How Medicare treats chiropractic E/M
Medicare Part B covers only manual manipulation of the spine to correct a subluxation when furnished by a chiropractor. Other services furnished or ordered by chiropractors, including E/M visits and X-rays, are not covered by Medicare. For Medicare patients, a chiropractor's E/M service is therefore a noncovered service. Practices should follow their Medicare contractor's guidance on how noncovered services are handled, including patient notices where applicable, and should never code a noncovered service as something else to obtain payment.
How commercial and other payers differ
Many commercial plans, Medicaid programs, auto insurance, and workers' compensation plans do pay for chiropractic E/M services when they are separately identifiable. Some limit new patient visits to one per year, some require re-evaluations at set intervals, and some bundle all E/M into manipulation regardless of documentation. Some plans route chiropractic care through a benefit manager that requires visit authorization. Keep a payer matrix showing which plans pay E/M with manipulation, what modifiers they expect, and visit limits.
Choosing the E/M level
Chiropractors use the same office E/M guidelines as other providers, selecting levels by medical decision making or total time on the date of service. Most chiropractic evaluations involve one or two musculoskeletal problems, limited data, and low risk, so documentation rarely supports the highest levels. If every new patient visit is billed at a high level, payers may flag the pattern. When time is used, the time spent performing the manipulation itself should not be counted toward the E/M.
Preventing denials
A short pre-claim check helps: confirm the payer covers chiropractic E/M, confirm the visit reason goes beyond the routine pre-manipulation assessment, verify modifier 25 is on the E/M and not on the manipulation code, and confirm the diagnoses support both services. Track denials by payer to identify plans that consistently bundle E/M, and update your matrix rather than repeatedly appealing claims the contract does not support.
Common documentation scenarios
A few scenarios come up often. A new patient presents after a car accident with neck and low back pain; the chiropractor performs a full history and examination, orders imaging, establishes a diagnosis and treatment plan, and performs the first adjustment. This visit often supports a new patient E/M with modifier 25 alongside manipulation for payers that cover both. An established patient returns for a scheduled re-evaluation after several weeks of care; the chiropractor documents objective measures, compares them to baseline, and modifies the plan. Depending on the payer, this may support an established patient E/M. An established patient arrives for a routine adjustment and mentions mild stiffness; the chiropractor checks the region and adjusts. That is a routine pre-manipulation assessment and does not support a separate E/M.
When a new complaint unrelated to the current treatment plan appears, such as a new shoulder injury, document it as its own problem with its own assessment and plan. Linking the correct diagnosis codes to each claim line, the E/M to the problems evaluated and the manipulation to the regions treated, helps reviewers see that the two services are distinct.
Frequently asked questions
How often can a chiropractic re-evaluation be billed?
There is no single national rule. Some commercial plans and benefit managers expect a formal re-evaluation at defined intervals, such as every set number of visits or weeks, while others allow one only when the condition changes. Document the reason for each re-evaluation, the objective findings compared to baseline, and how the plan changed, and follow each payer's published interval when one exists.
Does Medicare ever pay chiropractors for an E/M visit?
No. Medicare covers only spinal manipulation to correct subluxation when performed by a chiropractor. E/M services by chiropractors are not covered.
Can we bill an E/M every time a patient returns?
No. Routine pre-manipulation assessment is included in the manipulation code. A separate E/M needs a significant, separately identifiable reason documented in the note.
Where does modifier 25 go?
On the E/M code, not on the chiropractic manipulation code.
Sources and further reading
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This article is general information, not legal or coding advice. Always check current CPT®, ICD-10-CM, CMS and payer guidance. Questions? Contact us.