How to Bill for Maintenance vs. Corrective Chiropractic Care: Understanding the Critical Differences

Chiropractic billing has gotten trickier over the years, and the biggest headache is knowing when to bill corrective care versus maintenance therapy. Get this wrong and you’re looking at automatic denials, audit flags, and lost revenue. An OIG audit found that 82% of Medicare payments for chiropractic services were unallowable, primarily due to billing maintenance as active treatment.

What Is Corrective Chiropractic Care?

Corrective care is active treatment aimed at improving function. You’re working to restore spinal alignment, reduce pain, and boost mobility in patients with acute or chronic subluxation. Medicare and most insurers define it as treatment addressing specific neuromusculoskeletal conditions with clear, objective findings.

Think of it this way: you’re treating someone who just got hurt, dealing with symptoms that started recently, or managing chronic conditions where you genuinely expect things to get better. The proof is in the progress your patient’s pain is decreasing, they’re moving better, or they’re regaining function they’d lost. You’ve got a clear game plan with specific goals and timelines you’re working toward.

For billing, you’ll use CPT codes 98940 (1-2 spinal regions), 98941 (3-4 regions), or 98942 (5 regions) with the AT modifier. That modifier is your way of telling insurance companies, “Hey, this is active treatment, not just maintenance.”

Understanding Maintenance Chiropractic Care

Maintenance care is different. You’re keeping patients stable rather than making them better. It looks like preventive adjustments that keep patients at their current wellness level, supportive treatment that stops symptoms from getting worse, care provided after someone has reached their maximum improvement, and a focus on health promotion rather than restoring lost function.

Here’s where it gets tricky: Medicare won’t cover maintenance therapy. Most private insurance companies follow the same playbook.

The Critical Billing Differences

Corrective Care Billing Requirements

You need solid documentation proving medical necessity. Start with M99 subluxation codes as your primary diagnosis: M99.01 (cervical), M99.02 (thoracic), M99.03 (lumbar), M99.04 (sacral). Follow these up with supporting conditions like M54.2 (neck pain) or M54.5 (low back pain).

The AT modifier must be added to CPT codes 98940-98942. Skip this and your claim gets denied automatically. Analysis of over 10,000 Medicare claims shows missing modifiers cause 31% of denials.

Initial visits need a chief complaint, P-A-R-T examination (minimum 2 of 4 components, one must be Asymmetry or Range of motion), specific subluxation level, and measurable goals. Follow-ups require updated complaints, exam findings, condition assessment, and treatment details.

Medicare wants reassessment every 12 visits or 30 days showing at least 15% functional improvement. CMS data reveals 78% of denied visits beyond 12 cite insufficient evidence of need. Avoiding common chiropractic billing mistakes protects your revenue.

Maintenance Care Billing Approach

Get an Advance Beneficiary Notice of Noncoverage (ABN) before treating Medicare patients. If the patient agrees to pay (Option 1 on ABN), submit claims using CPT codes 98940-98942 with the GA modifier. Never use the AT modifier for maintenance. If you forgot an ABN, use the GZ modifier.

Some commercial payers cover limited maintenance care. When they do, use HCPCS code S8990 for physical or manipulative therapy performed for maintenance, but never for Medicare claims.

Many practices move maintenance patients to private payment, which cuts billing complexity but requires clear communication about costs. Effective denial management strategies help you spot when insurance coverage ends.

Documentation That Protects Your Practice

Good documentation supports claims, protects you during audits, and shows your clinical thinking. The SOAP format gives you the structure you need.

Document the patient’s chief complaint in their own words, including pain location, intensity (0-10 scale), and what makes it better or worse. Record what you actually measure. Don’t write “decreased range of motion.” Write “cervical rotation limited to 40 degrees right versus normal 80 degrees.”

Connect your findings to diagnosis codes and explain how your data supports the subluxation diagnosis. Detail what treatment you provided, which spinal regions you adjusted, goals, visit frequency, and timeline. Professional medical coding solutions make sure your documentation hits payer requirements.

Recognizing the Transition Point

Clinical plateaus happen when patients report the same symptoms across multiple visits without improvement. If pain scores and function stay stable for three or more visits, you’ve likely hit maximum benefit.

Treatment goals change when patients are satisfied with their progress and just want to prevent backsliding. That’s your shift into maintenance territory. Visit frequency is another clue. Active care usually means weekly visits. When you space things out to biweekly or monthly, that’s often your signal you’re in maintenance mode.

Current Compliance Landscape

Medicare audits of chiropractic practices jumped 47% from 2022 to 2024. Inadequate documentation is the culprit 89% of the time, with average overpayment recovery hitting $47,000 per audited practice.

Practices that document specific functional limitations with real numbers see 42% fewer denials. A 2025 compliance study found automated verification systems cut modifier errors by 87%. The ACA reports 30% of claims get denied initially, but practices that update coding and train staff regularly reduce denials by 25-40%.

Comparison Table: Corrective vs. Maintenance Care Billing

Billing Element	Corrective Care	Maintenance Care
Treatment Goal	Functional improvement expected	Prevent deterioration or promote wellness
Medicare Coverage	Covered when medically necessary	Not covered (non-payable)
CPT Codes	98940-98942 with AT modifier	98940-98942 with GA modifier or S8990 for private payers
Documentation	Must show objective improvement	Indicates plateau or maintenance phase
Patient Financial Responsibility	Standard copay/coinsurance	Often full out-of-pocket payment
ABN Requirement	Not required	Required for Medicare patients

Best Practices for Chiropractic Billing Success

Check eligibility and benefits before every appointment. Coverage changes monthly, so confirm visit limits, authorization needs, and specific chiropractic coverage.

Create initial plans with specific goals, visit frequency, and estimated timeline. Update every 12 visits or 30 days showing measurable progress. Monthly training sessions keep your team current on updates, focusing on recent CMS changes and common denial triggers. Understanding proper billing codes for chiropractors prevents submission mistakes.

Review random claim samples monthly before submission. Check documentation completeness, correct modifiers, and ensure accurate patient info. Have honest talks about coverage limits before transitioning to maintenance, giving patients written financial policies explaining when insurance stops.Modern chiropractic billing software with compliance checks cuts human error and streamlines workflows. Systems that flag missing modifiers boost claim acceptance rates, while working with experienced billing services helps you navigate carrier-specific differences and ensures accurate handling of both corrective and maintenance care claims.