Can You Bill 98941 and 98943 Together?

Medical billing for chiropractic services involves CPT codes 98941 and 98943, which describe chiropractic manipulative treatment (CMT). A common question is whether these codes can be billed together for the same patient on the same date of service. Understanding their appropriate application is important for compliant billing and accurate reimbursement.

Understanding CPT Codes 98941 and 98943

CPT code 98941 describes Chiropractic Manipulative Treatment (CMT) for three to four spinal regions. This code signifies manual manipulation to influence joint and neurophysiological function. The goal is to correct vertebral subluxations and enhance spinal alignment and function.

CPT code 98943 represents CMT performed on one or more extraspinal regions. This manipulation targets areas outside the spine, such as the head, upper or lower extremities, rib cage, or abdomen. Unlike 98941, which focuses on spinal segments, 98943 addresses other body joints and structures.

Spinal regions for CPT coding include five distinct areas: cervical (neck), thoracic (mid-back), lumbar (lower back), sacral (base of the spine), and pelvic (sacroiliac joint). While each region may contain multiple vertebrae, the number of regions treated determines the appropriate CPT code for spinal manipulation.

Rules for Billing Both Codes Together

CPT codes 98941 and 98943 represent different services and can be billed together for the same patient on the same date of service, provided specific conditions are met and documentation supports both. Code 98941 covers spinal manipulation, and 98943 covers extraspinal manipulation. For example, a chiropractor might treat three spinal regions (98941) and adjust a patient’s shoulder (98943) during the same visit.

Guidelines prevent “unbundling,” which is billing separately for procedures considered components of a single service. The National Correct Coding Initiative (NCCI) edits, maintained by Medicare, identify code pairs that should not be billed separately. While 98941 and 98943 are not bundled by NCCI edits, the services must be distinct and medically necessary.

When billing both codes, Modifier 59 (Distinct Procedural Service) is often required to indicate that the services were separate and independent from other non-Evaluation and Management (E/M) services performed on the same day. Modifier 59 signals to payers that a procedure was distinct due to a separate encounter, different structure, or other independent reason. If spinal manipulation (98941) and extraspinal manipulation (98943) address different anatomical sites, Modifier 59 can be appended to 98943. Medicare does not cover extraspinal manipulation (98943).

Ensuring Compliant Chiropractic Billing

All chiropractic services must be medically necessary and thoroughly documented. Medical necessity means the treatment is required to diagnose or treat an illness, injury, condition, or its symptoms. Documentation must clearly establish this necessity to avoid claim denials or audits.

Thorough documentation is paramount for supporting the chosen CPT code and justifying the level of service. Patient records should include the specific spinal or extraspinal regions treated, the nature of the manipulation, and clinical findings such as subluxations or joint dysfunction. It is also important to record the patient’s response to treatment and the overall treatment plan. For Medicare claims, the precise level of subluxation must be listed as the primary diagnosis, and the neuromusculoskeletal condition necessitating the treatment as the secondary diagnosis.

Providers should be aware that individual insurance payers may have specific policies or interpretations regarding CMT codes. It is advisable to verify patient eligibility and benefits with each payer before initiating treatment to understand any limitations or exclusions. Adherence to these documentation and payer-specific requirements is essential for accurate reimbursement and to maintain compliance with billing regulations.