What a clean chiropractic claim needs.

What “clean” means

A clean claim passes the clearinghouse’s and the payer’s front-end checks and can be processed without the payer asking you for anything else. A claim that fails those checks is rejected before anyone decides payment; the guide to rejected and denied claims explains the difference. A clean claim can still be denied for coverage or medical necessity, but it will not be returned for a missing field.

The checklist below follows the order of the claim itself: who is billing, where and when, what was done, why, and the modifiers that tie them together.

Who is billing: identifiers

• Billing provider. The practice’s NPI, tax ID and taxonomy, matching the payer’s file. The billing provider address must be a street address; a post office box belongs in the pay-to address.
• Rendering provider. When the chiropractor who saw the patient is not the billing provider, the claim names the rendering provider’s own NPI.
• Payer. The right payer ID for the plan, which may be a separate company that manages chiropractic benefits. The guide to checking coverage covers how to tell.
• Patient and subscriber. The member ID, name and date of birth exactly as the payer has them, and the patient’s relationship to the subscriber.

Where and when: place of service and dates

• Place of service. Code 11, Office, for visits in your clinic.
• Date of service on every line.
• Initial treatment date. Medicare requires the date of the initial treatment, or of an exacerbation of an existing condition, on chiropractic claims: item 14 of the CMS-1500, or the 837P’s DTP segment with qualifier 454. A missing date comes back with remark code MA122. Some commercial payers ask for it too. Read it from the signed note. Medicare stopped requiring an x-ray to show the subluxation in 2000.

What was done: the CMT code

Chiropractic manipulative treatment is billed by the number of spinal regions treated, counted from the signed note:

Count the regions the note documents, not the regions on last week’s claim. Extraspinal manipulation (98943) is a separate code, and Medicare does not cover it.

Two combinations trip up many chiropractic claims. An office visit on the same day as CMT needs a significant, separately identifiable evaluation in the note before it gets its own line and modifier. Manual therapy on the same region as the adjustment is bundled under the National Correct Coding Initiative; a distinct-region modifier belongs on it only when the note shows a different region. The guide to chiropractic denial codes covers the denials each one produces.

Why: diagnoses in order

• Segmental dysfunction first. One segmental dysfunction code (M99.0-) for each region adjusted, listed before anything else. Medicare requires the precise level of the subluxation to be documented and reported as the primary diagnosis.
• Symptoms and conditions second. Pain and other codes follow, as the note supports them.
• Pointers that match. Each service line points to the diagnoses that support it. A CMT line that points only to a symptom code invites a denial for diagnosis inconsistent with the procedure.
• Regions that agree. The number of segmental dysfunction codes should support the CMT code on the line.

Modifiers

• AT on each CMT line the note supports as active treatment, where the payer requires it. Medicare does, and treats a CMT line without it as maintenance.
• GA when a Medicare patient signed an Advance Beneficiary Notice before the visit.
• 25 on an office visit billed the same day as CMT, only when the note documents a significant, separately identifiable evaluation.
• A distinct-procedure modifier on a therapy line, only when the note shows a different region from the adjustment.

Every modifier is a statement about the note. If the note does not say it, the claim should not either.

A pre-send checklist

1. The note is signed.
2. Coverage was checked for this date of service.
3. Billing provider, rendering provider and payer ID are right for this plan.
4. Member ID, name and date of birth match the eligibility response.
5. The CMT code matches the regions in the note.
6. Segmental dysfunction codes come first, one per region adjusted.
7. Each line points to the diagnoses that support it.
8. Modifiers match what the note says and what the payer requires.
9. The initial treatment date is present where the payer expects it.
10. The charge matches your fee schedule.

Each check matches a rejection or denial reason covered in After the claim goes out. Catching it here costs a minute; catching it on the remittance costs a resubmission and weeks of waiting.

How Claims Native checks each claim

We check each CMT claim against the signed note before it goes out: the AT modifier on each line the note supports as active treatment, the CMT code against the number of spinal regions in the note, a segmental dysfunction code for each region listed first, symptom codes second, and the initial treatment date read from the note, where the payer expects it. We read the note; we never change it. When the note does not support the claim, the question goes to your provider, once, and your provider decides what the note says.

Sources

• CMS, Transmittal 137: chiropractic claims. Initial treatment date in item 14; x-ray no longer required.
• Noridian, Chiropractic services: initial treatment date. Loop 2300 DTP*454; remark code MA122.
• CMS, Medicare Benefit Policy Manual, Chapter 15, section 240. Chiropractic coverage and the precise level of subluxation.
• CMS, MLN Matters SE1601: Medicare coverage of chiropractic services. CMT codes and regions.
• CMS, Place of service code set.
• CMS, Version 5010 national call. Billing provider street address.