Georgia Medicare Chiropractic Coverage

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By Brevy Care Team · Last verified May 13, 2026

Section 1861(r)(5) of the Social Security Act recognizes doctors of chiropractic as Medicare providers, but only for one service: manual manipulation of the spine to correct a subluxation. Medicare does not cover chiropractor-ordered x-rays, chiropractor-performed examinations, acupuncture, electrical stimulation, ultrasound, massage, traction, physical therapy under chiropractor supervision, nutritional counseling, or any other service furnished by a chiropractor. This guide explains the 42 CFR 410.21 chiropractor definition, the 42 CFR 410.22 coverage limitation, the NCD 240.1.3 PART documentation criteria, the AT modifier active-treatment requirement established in October 2004, the CPT 98940 to 98942 hierarchy and the non-covered extraspinal code 98943, payment under the Physician Fee Schedule, opt-out and non-participating provider rules, Medicare Advantage chiropractic supplemental benefits, and how Georgia beneficiaries access chiropractic care under one of the narrowest Part B benefit definitions in the entire Medicare program. :::

::: callout Key takeaways

• Section 1861(r)(5) of the Social Security Act, added by the 1972 Social Security Amendments (Public Law 92-603, Section 273), recognizes chiropractors as Medicare providers limited to manual spinal manipulation only.
• 42 CFR 410.22 explicitly excludes from coverage any laboratory tests, x-rays, office visits, consultations, physiotherapy, acupuncture, nutritional supplements, and other diagnostic or therapeutic services ordered or performed by a chiropractor.
• NCD 240.1.3 requires documentation of subluxation either through x-ray (within 12 months before or 3 months after start of treatment) OR through physical examination demonstrating at least two of four PART criteria, one of which must be asymmetry/misalignment or range-of-motion abnormality.
• The AT modifier (Active Treatment) is required on every Medicare-billed chiropractic claim. Claims without the AT modifier are denied as maintenance therapy.
• CPT 98940 (1-2 spinal regions), 98941 (3-4 regions), and 98942 (5 regions) are covered. CPT 98943 (extraspinal manipulation) is statutorily excluded.
• Cost-sharing: $257 Part B deductible (2026), then 20% beneficiary coinsurance. Medicare Advantage plans may offer supplemental chiropractic benefits including covered examinations and x-rays.
• Non-participating chiropractors may charge up to the limiting charge (115% of non-par fee schedule). Opt-out chiropractors require private contracts that waive Medicare coverage entirely.
• Georgia has approximately 3,500 licensed chiropractors regulated by the Georgia Board of Chiropractic Examiners under O.C.G.A. §43-9. Life University in Marietta is the largest chiropractic college in the Southeast. :::

The narrowest Part B benefit: why Medicare chiropractic coverage works the way it does

Manual manipulation of the spine to correct a subluxation. That single phrase: thirteen words: is the entire Medicare chiropractic benefit. Everything else a chiropractor might do during a visit, from the initial examination to the x-ray to the post-adjustment massage to the supplement recommendation, falls outside what Medicare pays for. A beneficiary who walks into a chiropractor's office expecting comprehensive coverage will leave bewildered when the front desk presents a separate bill for everything except the manipulation itself.

This benefit structure is not accidental. It dates to a specific compromise reached in 1972, when Congress added chiropractors to the Medicare program through Section 273 of the Social Security Amendments of 1972 (Public Law 92-603). At the time, the medical profession and the chiropractic profession were locked in a decades-long dispute about whether chiropractic care was a legitimate health service. Congress resolved the dispute by recognizing chiropractors as Medicare providers but limiting coverage to the one service the profession itself uniquely identified as its core practice: manual spinal manipulation to correct subluxation. The compromise codified at Section 1861(r)(5) of the Social Security Act has remained essentially unchanged for over 50 years.

The Office of Inspector General has documented for more than two decades that a substantial percentage of Medicare-paid chiropractic claims do not meet coverage requirements: typically due to missing or inadequate documentation of subluxation, missing AT modifiers, or services billed during maintenance therapy phases. OIG report OEI-07-04-00260 (May 2005) found that 41% of paid chiropractic claims did not meet Medicare coverage requirements. OIG report OEI-07-09-00500 (December 2009) reached similar conclusions. As a result, chiropractic remains one of the highest-audit-risk specialties in Medicare, and Palmetto GBA (the Jurisdiction J Medicare Administrative Contractor for Georgia) routinely conducts prepay and postpay medical review of chiropractic claims.

For Georgia beneficiaries, the practical consequence is that walking into a chiropractor's office without understanding the Section 1861(r)(5) limitation almost always results in unexpected out-of-pocket costs. The chiropractor may be well-intentioned, the services may be medically appropriate, the patient may benefit clinically, but Medicare's coverage rules will pay only for the spinal manipulation portion. This guide explains exactly how the benefit works, what counts as covered manipulation, what documentation is required, how to identify participating versus non-participating versus opt-out chiropractors, and how to avoid the most common errors.

Federal statutory framework: Section 1861(r)(5) and the 1972 Social Security Amendments

Section 1861(r) defines who counts as a physician

Section 1861(r) of the Social Security Act, titled "Physician," establishes who Medicare recognizes as a physician for purposes of Part B coverage. The section enumerates five categories:

Section 1861(r)(5) reads in relevant part: "...a chiropractor who is licensed as such by the State or, in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which the chiropractor performs such services, and who meets uniform minimum standards promulgated by the Secretary... but only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation)..."

The final clause: "but only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation)": is the source of the entire coverage limitation. While the other physician categories in Section 1861(r) are recognized for the full scope of their practice, chiropractors are recognized only for one specific service.

The 1972 Social Security Amendments: how chiropractors were added

The Social Security Amendments of 1972 (Public Law 92-603) were signed by President Richard Nixon on October 30, 1972. Section 273 of the Act amended Section 1861(r) of the Social Security Act to add chiropractors as the fifth category of physician. The provision took effect July 1, 1973.

The 1972 amendment was the culmination of a multi-year lobbying effort by the American Chiropractic Association and the International Chiropractors Association. The amendment was opposed by the American Medical Association, which at the time still characterized chiropractic as "unscientific." The compromise reached: recognition of chiropractors as Medicare providers but limited to manual spinal manipulation for subluxation: reflected the political reality of the time.

The compromise has been remarkably durable. Despite 50+ years of advocacy by the chiropractic profession to expand the benefit, the only meaningful change has been the 2003 demonstration project under MMA 2003 Section 651, which tested expanded chiropractic services in five sites between April 2005 and March 2007. The demonstration concluded that expanded services did not produce cost savings or improved outcomes (per-beneficiary spending in demonstration areas was approximately 40% higher than in comparison areas), and Congress did not extend the expansion. Section 1861(r)(5) remains as it has been since 1973.

42 CFR 410.21: who qualifies as a chiropractor

The Centers for Medicare and Medicaid Services implements Section 1861(r)(5) through 42 CFR 410.21, which defines who qualifies as a chiropractor for Medicare purposes. The regulation requires:

1. The chiropractor is licensed or legally authorized to furnish chiropractic services by the state or jurisdiction in which the services are furnished.
2. The chiropractor has satisfied a uniform minimum standard of education.

The uniform minimum standard of education requires graduation from a chiropractic college accredited by the Council on Chiropractic Education (CCE) after 1973, OR documented evidence of having met state licensure requirements equivalent to a CCE-accredited program.

In Georgia, all licensed chiropractors graduated from CCE-accredited programs (the most common being Life University in Marietta, Sherman College in Spartanburg SC, and Palmer College of Chiropractic in Davenport IA), so the educational standard is uniformly met. Georgia chiropractors are licensed by the Georgia Board of Chiropractic Examiners under O.C.G.A. §43-9.

42 CFR 410.22: the covered chiropractic service

42 CFR 410.22 is the operative coverage regulation. Section (a) states that Medicare Part B pays for chiropractic services only when furnished by a chiropractor who meets the qualifications in 42 CFR 410.21, AND the service is manual manipulation of the spine to correct a subluxation.

Section (b) of 42 CFR 410.22 explicitly EXCLUDES from coverage:

• Laboratory tests
• X-rays (when ordered or performed by a chiropractor)
• Office visits and consultations
• Physiotherapy
• Acupuncture
• Nutritional supplements
• Other diagnostic or therapeutic services performed or ordered by a chiropractor

This exclusion list is comprehensive and absolute. No matter how medically appropriate any of these services may be, if ordered or performed by a chiropractor, Medicare does not pay. The same x-ray ordered by an M.D. or a D.O. would be covered under the diagnostic radiology benefit. The same x-ray ordered by a D.C. is statutorily excluded.

The same logic applies to physical therapy. PT services furnished by a chiropractor are not covered. PT services furnished by a qualified physical therapist under 42 CFR 410.59-60 ARE covered. The distinction is the provider, not the service.

Documentation: NCD 240.1.3 and the PART criteria

What is a subluxation?

National Coverage Determination 240.1.3 (Manual Manipulation of the Spine to Correct a Subluxation) defines subluxation as "a motion segment in which alignment, movement integrity, and/or physiologic function of the spine are altered, although contact between joint surfaces remains intact."

This is the chiropractic profession's clinical definition adopted by CMS. The definition emphasizes that the joint surfaces remain in contact: distinguishing subluxation from medical/orthopedic dislocation, in which joint surfaces are completely separated.

For Medicare coverage, the subluxation must be:

1. Specifically identified at a particular spinal level (cervical, thoracic, lumbar, sacral, or pelvic)
2. Documented through either x-ray or physical examination
3. Linked to the patient's symptoms
4. Addressed by the spinal manipulation furnished

Method one: x-ray demonstration

The subluxation may be documented by an x-ray showing visible misalignment. NCD 240.1.3 requires the x-ray to be taken at a time reasonably proximate to the initiation of a course of treatment:

• Generally within 12 months prior to the first day of treatment, OR
• Within 3 months after the start of treatment

The chiropractor does not need to take the x-ray; the x-ray can be obtained from any source (e.g., a prior x-ray taken by a primary care physician or emergency department). However, Medicare does NOT pay for the x-ray if ordered or performed by a chiropractor. The beneficiary or another payer (Medicare Advantage, secondary insurance) pays for the x-ray itself.

Method two: physical examination (PART criteria)

The subluxation may alternatively be documented by physical examination using the PART criteria. PART stands for:

The chiropractor must document at least TWO of the four criteria. One of the two MUST be either asymmetry/misalignment (A) or range-of-motion abnormality (R). Pain plus tissue tone changes alone is NOT sufficient: at least one of the structural findings (A or R) must be present.

The PART documentation must be present in the medical record before each manipulation is furnished. Updated documentation must demonstrate continued presence of the subluxation throughout the treatment course.

Treatment plan requirement

NCD 240.1.3 requires the chiropractor to develop a treatment plan that includes:

• Recommended level of care (number of visits and frequency)
• Specific treatment goals (e.g., reduction in pain rating, restored range of motion)
• Objective measures used to evaluate effectiveness

The treatment plan must be reviewed periodically and updated as the patient's condition changes.

Active treatment versus maintenance therapy

This distinction is the most consequential coverage rule and the source of the highest volume of chiropractic claim denials.

Medicare covers ACTIVE TREATMENT to address an acute condition or to support functional recovery. Active treatment includes:

• Treatment of an acute subluxation following injury
• Treatment of a chronic subluxation during a documented exacerbation
• Treatment expected to result in measurable improvement within a reasonable timeframe

Medicare does NOT cover MAINTENANCE THERAPY. Maintenance therapy is:

• Continued treatment after maximum therapeutic benefit has been reached
• Treatment aimed at preventing recurrence of symptoms
• Treatment that maintains the status quo without further improvement expected
• "Tune-up" or "wellness" visits unrelated to an acute or exacerbated condition

The chiropractor is responsible for determining when active treatment has concluded and maintenance therapy has begun. Once maintenance begins, the chiropractor must obtain an Advance Beneficiary Notice (ABN) before continuing to bill the beneficiary.

The AT modifier and the October 2004 transmittal

The AT (Active Treatment) modifier is required on every Medicare-billed chiropractic claim. CMS established the AT modifier requirement through Change Request 3449, Transmittal 88, dated October 8, 2004, effective for claims with dates of service on or after October 1, 2004.

The AT modifier is the chiropractor's certification that:

1. The service represents active or corrective treatment
2. The beneficiary has documented subluxation
3. A treatment plan exists
4. The service is not maintenance care

Claims billed WITHOUT the AT modifier are automatically denied as maintenance therapy. This is a hard edit in the Medicare claims processing system; no human reviewer is needed to deny the claim.

The AT modifier was introduced after the 2005 OIG report documented widespread improper payments for chiropractic maintenance therapy. By requiring the chiropractor to affirmatively attest to active treatment on every claim, CMS placed the certification burden on the provider and clarified that maintenance therapy was unambiguously non-covered.

Audit risk: chiropractors who routinely apply the AT modifier without supporting documentation in the medical record face audit recoupment, civil monetary penalties, and potential exclusion from the Medicare program. Palmetto GBA in Jurisdiction J conducts targeted prepayment review of chiropractic claims.

CPT code hierarchy: 98940 through 98943

Chiropractic manipulative treatment is reported using a small set of CPT codes that escalate by the number of spinal regions treated.

Spinal regions defined

For CPT coding purposes, the spine is divided into FIVE regions:

Covered CPT codes

The chiropractor codes based on the regions actually manipulated during the visit and supported by documentation. A beneficiary cannot upcode to a higher code simply by adding additional manipulations without documenting subluxation at each region.

Non-covered CPT code

CPT 98943 covers manipulation of extraspinal regions: head (excluding occipital), upper extremities, lower extremities, rib cage (excluding costotransverse and costovertebral joints), and abdomen. Because Section 1861(r)(5) limits coverage to manual manipulation of the SPINE, extraspinal manipulation is statutorily excluded regardless of medical necessity.

When a chiropractor performs CPT 98943, the beneficiary is personally responsible for payment. The chiropractor should:

• Obtain a signed Advance Beneficiary Notice (ABN) before furnishing the service
• Use the GA modifier on the claim to indicate ABN on file, OR
• Use the GY modifier to indicate statutorily excluded service (for secondary payer billing purposes)

Frequency considerations

Medicare does not specify a maximum number of chiropractic visits per year. However, the MAC may apply local screening edits that flag claims exceeding certain volume thresholds (commonly 12-24 visits per year per beneficiary) for medical review. Beneficiaries receiving high-volume chiropractic care should expect the MAC may request medical records.

Payment under the Physician Fee Schedule

Chiropractic services are paid under the Medicare Physician Fee Schedule (MPFS). The fee schedule amount equals: (Work RVU × Work GPCI) + (PE RVU × PE GPCI) + (MP RVU × MP GPCI), multiplied by the conversion factor.

Georgia GPCI localities

Georgia has two Physician Fee Schedule localities:

Atlanta locality payments are slightly higher than Rest of Georgia. The difference is modest: approximately 3-5% across most CPT codes.

2026 approximate payment amounts

For Rest of Georgia locality (subject to annual MPFS final rule):

Atlanta locality amounts are approximately 2-3% higher.

Cost-sharing

• Part B annual deductible: $257 (2026, applied to the first $257 of approved charges)
• After deductible: 20% beneficiary coinsurance
• Medicare pays 80% of approved amount

Medigap coverage: All standardized Medigap plans cover the 20% Part B coinsurance for covered services. Plan G is the most popular and covers the 20% in full after the beneficiary pays the $257 deductible. Plan F (grandfathered for those enrolled before 2020) covers both the deductible and the coinsurance.

Provider participation status: three categories

Chiropractors fall into one of three participation categories that determine how much the beneficiary pays.

Category one: participating providers

A participating provider has signed a Medicare participation agreement and accepts assignment on all Medicare claims. The provider:

• Submits the claim directly to Medicare
• Receives 80% of the approved amount from Medicare
• Collects only the 20% coinsurance (and deductible if not met) from the beneficiary
• Cannot balance bill above the approved amount

For a participating chiropractor in Georgia billing CPT 98941, the beneficiary pays $8.80 coinsurance (or $0 with Plan G/F Medigap).

Category two: non-participating providers

A non-participating provider has NOT signed a participation agreement but may still accept assignment on a claim-by-claim basis. Non-participating providers face two important rules:

1. The non-par fee schedule amount is 95% of the par amount
2. If the non-par provider does NOT accept assignment, the provider may charge up to the LIMITING CHARGE = 115% of the non-par amount

Example: CPT 98941 par amount in Georgia: $44

The third row is the most expensive scenario. The non-par chiropractor charges the beneficiary the limiting charge of $48.07 up front. The beneficiary pays out of pocket. The chiropractor files the Medicare claim. Medicare pays $33.44 to the beneficiary as reimbursement. The beneficiary's net cost is $48.07 - $33.44 = $14.63.

Medigap policies typically pay the standard 20% coinsurance but do NOT pay balance billing above the Medicare approved amount. The beneficiary therefore pays more out of pocket with a non-par no-assignment chiropractor than with a participating chiropractor, even with Medigap.

Category three: opt-out providers

An opt-out chiropractor has filed an affidavit with the MAC stating that he or she will not accept Medicare payment for any service for two years. Opt-out chiropractors require beneficiaries to sign a PRIVATE CONTRACT before furnishing services.

The private contract:

• States that the chiropractor has opted out of Medicare
• States that Medicare will not pay for any services from this chiropractor
• States that the beneficiary agrees to pay the chiropractor's full retail charges
• Waives any right to reimbursement from Medicare for services received from this chiropractor

Opt-out is binding for two years. The chiropractor must re-affirm opt-out status every two years to maintain it.

For beneficiaries, signing an opt-out private contract means:

• Pay the chiropractor's full retail rate (typically $80-100 per visit)
• Cannot file claims with Medicare
• Medigap pays NOTHING (Medigap pays only Medicare-covered services)
• Medicare Advantage plans may pay something through out-of-network benefits but typically little

Beneficiaries should think carefully before signing an opt-out private contract. The cost difference compared to a participating chiropractor can exceed $1,000 per year for monthly visits.

Finding a participating chiropractor in Georgia

To find a participating Medicare chiropractor in Georgia:

1. Use the Medicare.gov "Find a Provider" tool at medicare.gov/care-compare. Filter for chiropractor specialty and accepting Medicare assignment.
2. Call Medicare 1-800-MEDICARE for chiropractor listings.
3. Ask the chiropractor's office directly whether the provider accepts Medicare assignment. Get the answer in writing if possible.
4. Confirm participation status before each visit. Status can change.

Medicare Advantage chiropractic supplemental benefits

Medicare Advantage (MA) plans must cover everything Original Medicare covers (manual spinal manipulation), but MA plans may add SUPPLEMENTAL chiropractic benefits. These supplemental benefits are valuable because they fill gaps in Original Medicare coverage.

Common MA supplemental chiropractic benefits:

• Coverage for routine chiropractor examinations (not covered by Original Medicare)
• Coverage for chiropractor-ordered x-rays (not covered by Original Medicare)
• Coverage for additional visits beyond medical necessity standards
• Coverage for extraspinal manipulation (CPT 98943, not covered by Original Medicare)
• Lower flat-fee copays ($20-30 per visit instead of 20% coinsurance)
• Coverage of related alternative therapies (acupuncture, massage, electrical stimulation)

Georgia MA plans with chiropractic supplemental benefits include various plans from Humana, UnitedHealthcare, Aetna, WellCare, Anthem, and Wellstar/Cigna. Specific benefit structures vary plan by plan and can change year over year.

Beneficiaries should:

• Read the plan's Evidence of Coverage (EOC) before enrolling
• Confirm the chiropractor is in the plan's network
• Understand the annual visit limit and any prior authorization requirements
• Compare premium and copay structures across plans during the Annual Election Period (October 15 to December 7 each year)

The GeorgiaCares State Health Insurance Assistance Program (SHIP) at 1-866-552-4464 provides free counseling on MA plan selection and chiropractic benefit comparisons.

The MMA 2003 Section 651 demonstration project

The Medicare Modernization Act of 2003 (Public Law 108-173) Section 651 directed CMS to conduct a 2-year demonstration project testing expanded chiropractic services. The demonstration:

• Ran from April 1, 2005 through March 31, 2007
• Tested coverage of chiropractic care for neuromusculoskeletal conditions other than subluxation
• Tested coverage of diagnostic and therapeutic services within the chiropractor's scope of practice
• Was implemented in five sites: Chicago IL, Detroit MI, Hartford-Springfield-New Haven CT, two areas in Iowa, and Northern Virginia

The CMS Report to Congress concluded that expanded chiropractic services:

• Did NOT produce cost savings
• Did NOT produce improved beneficiary outcomes
• Resulted in per-beneficiary spending approximately 40% higher in demonstration areas than in comparison areas

Congress did not act to extend or make permanent the expansion. Medicare chiropractic coverage therefore reverted to the Section 1861(r)(5) baseline at the conclusion of the demonstration. Subsequent legislative proposals (Chiropractic Medicare Coverage Modernization Act and Medicare Manual Therapy Modernization Act) have been introduced repeatedly but have not been enacted.

Georgia chiropractic licensure: O.C.G.A. §43-9

The Chiropractic Practice Act

Title 43, Chapter 9 of the Official Code of Georgia Annotated (O.C.G.A. §43-9) governs chiropractic practice in Georgia. Key provisions:

• O.C.G.A. §43-9-1: Definitions
• O.C.G.A. §43-9-2: Georgia Board of Chiropractic Examiners
• O.C.G.A. §43-9-7: Licensure requirements
• O.C.G.A. §43-9-16: Scope of practice
• O.C.G.A. §43-9-17: Prohibited acts

Scope of practice in Georgia

O.C.G.A. §43-9-16 defines chiropractic practice as the adjustment of the articulations of the spinal column and its appendages, including the analyzing of the human body to determine interference with normal function caused by displacement or subluxation of the spine.

Georgia chiropractors are authorized to:

• Perform spinal adjustments and manipulations
• Conduct physical examinations
• Order and interpret x-rays
• Provide nutritional counseling
• Recommend exercise and rehabilitation programs
• Use physiotherapeutic modalities (ultrasound, electrical stimulation, traction)
• Perform extraspinal manipulation (within the scope of practice)

Georgia chiropractors are NOT authorized to:

• Prescribe drugs (medication)
• Perform surgery
• Practice obstetrics
• Use injection therapy

The state scope of practice is BROADER than what Medicare covers. A Georgia chiropractor can lawfully order x-rays and conduct nutritional counseling within state scope. Medicare simply does not pay for those services when ordered by a chiropractor. The chiropractor must therefore bill the beneficiary for those services or seek payment from secondary insurance or Medicare Advantage supplemental benefits.

Georgia Board of Chiropractic Examiners

The Georgia Board of Chiropractic Examiners administers chiropractor licensure under O.C.G.A. §43-9-2. The Board consists of seven members: six licensed chiropractors and one consumer member, all appointed by the Governor.

Contact:

• Address: 237 Coliseum Drive, Macon, GA 31217
• Phone: 478-207-2440 (Professional Licensing Boards Division)
• Email: chiroplb@sos.ga.gov

The Board:

• Issues and renews chiropractor licenses
• Conducts disciplinary proceedings for licensure violations
• Approves continuing education programs
• Handles consumer complaints about chiropractor conduct

Complaints about chiropractor conduct (scope violations, ethical breaches, unprofessional behavior) should be filed with the Board. Complaints about Medicare billing fraud should be filed separately with Medicare or HHS OIG.

Georgia Chiropractic Association

The Georgia Chiropractic Association is the state professional society. Contact: Atlanta, 770-723-1100.

The Association:

• Advocates for chiropractic interests at the General Assembly
• Provides continuing education programs
• Maintains a member directory
• Publishes scope of practice guidance for members

Life University in Marietta

Life University is the largest chiropractic college in the Southeast and one of the largest in the world. Located in Marietta, Georgia, Life University graduates approximately 200 D.C. recipients per year. Many graduates remain in Georgia for practice, contributing to the state's relatively high chiropractor density.

Six worked examples for Georgia beneficiaries

Example one: Margaret 76 Atlanta lower back pain treated by participating chiropractor

Margaret is a 76-year-old retired teacher in Atlanta. She has been experiencing lower back pain for three weeks. She visits a participating chiropractor at a Sandy Springs practice. The chiropractor performs a physical examination, documents range-of-motion abnormality and tenderness in the lumbar region (two of four PART criteria, including required range-of-motion abnormality), establishes a treatment plan, and performs spinal manipulation of the thoracic, lumbar, and pelvic regions.

CPT 98941 (3-4 region CMT) with AT modifier is billed. Medicare-approved amount is $44. Margaret has met her 2026 Part B deductible. Medicare pays 80% = $35.20. Margaret's 20% coinsurance = $8.80. Margaret has Medigap Plan G, which pays the $8.80. Margaret pays $0 out of pocket for the manipulation.

The chiropractor recommends 6 visits over 4 weeks. After 6 visits, documentation shows reduced pain (from 7/10 to 2/10), improved range of motion, and resolution of subluxation findings. The treatment is concluded. Margaret's total cost for the entire active treatment phase: $0 (covered by Medicare and Medigap).

Example two: Robert 81 Savannah neck pain learns x-ray is not covered

Robert is an 81-year-old retired shipping executive in Savannah. He has chronic neck pain. He visits a participating chiropractor who recommends an x-ray to evaluate cervical alignment before initiating treatment. The chiropractor performs the x-ray in office at a charge of $75 and then performs cervical and thoracic manipulation (CPT 98940, 2 regions).

Medicare pays 80% of the $32 approved amount for CPT 98940 = $25.60. Robert pays $6.40 coinsurance. Robert has Medigap Plan F (grandfathered, enrolled before 2020), which pays the $6.40.

Medicare does NOT pay for the x-ray. The chiropractor provided an Advance Beneficiary Notice (ABN) before the x-ray and obtained Robert's signature. Robert is responsible for the full $75.

Total Robert paid: $75 (x-ray, paid out of pocket). Medicare + Medigap covered the manipulation. Robert is surprised to learn that the x-ray is not covered when ordered by a chiropractor. If Robert's primary care physician had ordered the same x-ray at the hospital outpatient imaging department, Medicare would have covered 80% of the approved amount under the diagnostic radiology benefit.

Example three: Linda 74 Macon balance-billed by non-participating chiropractor

Linda is a 74-year-old in Macon. She visits a non-participating chiropractor who does not accept assignment. The chiropractor performs CPT 98941 (3 regions).

The 2026 fee schedule for CPT 98941 in Rest of Georgia locality:

• Participating amount: $44
• Non-participating amount (95% of par): $41.80
• Limiting charge (115% of non-par): $48.07

The non-participating chiropractor charges Linda $48 (within the limiting charge ceiling). Linda pays the chiropractor $48 directly. The chiropractor files the Medicare claim. Medicare reimburses Linda 80% of the non-par amount = $33.44.

Linda's net out-of-pocket: $48 (paid) - $33.44 (Medicare reimbursement) = $14.56.

If Linda had Medigap, the Medigap would pay 20% of the approved non-par amount = $8.36. Linda's net cost with Medigap: $48 - $33.44 - $8.36 = $6.20. Even with Medigap, Linda pays more than she would have paid a participating chiropractor ($0 with Plan G).

The structural problem is that Medigap pays only the Medicare-approved coinsurance, not the balance billing above the approved amount. The $6.20 difference is what economists call the "limiting charge gap." For beneficiaries, the practical advice is to choose participating chiropractors whenever possible.

Example four: Charles 79 Augusta maintenance care denied without AT modifier

Charles is a 79-year-old in Augusta who has been seeing a chiropractor for two years for chronic neck pain. He visits monthly for what his chiropractor describes as "tune-ups." His chiropractor bills CPT 98940 each visit but, recognizing the visits are maintenance care, does not include the AT modifier.

Medicare denies each claim as maintenance therapy (not covered). The chiropractor provided an ABN at the first maintenance visit, and Charles signed it. Charles is responsible for the full charge each visit.

Charles believes Medicare should cover these visits because he sees them as preventive care that keeps his neck pain from getting worse. The chiropractor explains that Medicare distinguishes active corrective treatment from maintenance therapy. Active treatment addresses an acute or exacerbated condition and produces measurable improvement. Maintenance therapy maintains the status quo or prevents recurrence without further improvement expected.

Charles has options:

1. Pay out of pocket for ongoing monthly maintenance visits
2. Ask the chiropractor to assess whether Charles's condition has acutely worsened (an exacerbation), which could justify a new course of active treatment with the AT modifier
3. Consider switching to a Medicare Advantage plan that includes a chiropractic supplemental benefit covering routine maintenance visits

Charles ultimately decides to switch to an MA plan during the next Annual Election Period that covers up to 20 chiropractic visits per year with a $25 copay regardless of active or maintenance status.

Example five: Patricia 72 Columbus Medicare Advantage supplemental benefit

Patricia is a 72-year-old in Columbus enrolled in a Humana Medicare Advantage plan with chiropractic supplemental benefits. The plan covers 20 chiropractic visits per year with a $20 copay per visit. The plan also covers routine examinations and chiropractor-ordered x-rays as part of the supplemental benefit.

Patricia visits a network chiropractor for upper back pain. She receives:

• An initial examination
• An x-ray to evaluate thoracic alignment
• CPT 98941 spinal manipulation

She pays the $20 copay for the visit. The MA plan pays the chiropractor's network rate for all three services (examination, x-ray, manipulation) at no additional cost-sharing to Patricia.

If Patricia had Original Medicare, she would have paid:

• 20% coinsurance on $44 (manipulation) = $8.80 (or $0 with Medigap)
• Full charge for examination = approximately $60
• Full charge for x-ray = approximately $75
• Total: $135.80 (or $135 with Medigap)

Her MA supplemental benefit produces meaningful savings: $20 instead of $135.80, a difference of $115.80 per visit. Over a year of monthly visits, the supplemental benefit saves Patricia approximately $1,390.

Patricia should still confirm the chiropractor is in the plan's network, understand the 20-visit annual limit, and know whether prior authorization is required beyond a threshold (some plans require prior auth for visits 11-20).

Example six: Henry 83 rural Tifton opt-out chiropractor private contract

Henry is an 83-year-old farmer in rural Tifton with chronic lower back pain from decades of agricultural work. The local chiropractor is one of the few in the area and has opted out of Medicare. The chiropractor presents Henry with a private contract that:

• Acknowledges the chiropractor has opted out of Medicare for two years
• States that Medicare will not pay for any services
• States that Henry agrees to pay the chiropractor's full retail charges
• Waives any right to reimbursement from Medicare for services received from this chiropractor

The contract is binding for two years.

Henry has two options:

1. Sign the contract and pay full retail (typically $80-100 per visit for spinal manipulation in this area)
2. Travel to Albany (40 miles) or Valdosta (50 miles) to find a participating chiropractor

Henry signs the contract because the travel is not feasible. Over a year of monthly visits, Henry pays approximately $1,200 out of pocket. He cannot file claims with Medicare. His Medigap policy provides no benefit because Medicare has not paid anything.

If Henry had been enrolled in a Medicare Advantage plan with out-of-network chiropractic coverage, the plan might have paid something toward the opt-out chiropractor's charges, though typically with higher cost-sharing than in-network. Henry should evaluate MA options during the next AEP.

This example illustrates the rural access problem in Georgia that frequently forces beneficiaries into opt-out private contracts. The Georgia Chiropractic Association and CMS have not produced a meaningful solution to this access gap.

Fourteen common mistakes Georgia beneficiaries make

Mistake one: assuming all chiropractor services are covered

Medicare beneficiaries often expect Medicare to cover the complete chiropractor visit including consultation, examination, x-ray, and manipulation. Medicare covers only the manual spinal manipulation. Everything else is the beneficiary's responsibility (or another payer's).

Mistake two: assuming a physician referral is required

No physician referral is required for chiropractic services under Original Medicare. The chiropractor can self-refer. However, Medicare Advantage plans may require referral or prior authorization, particularly for higher-volume visits.

Mistake three: missing the AT modifier

If the chiropractor bills without the AT modifier, the claim will be denied as maintenance therapy. The beneficiary may be unaware that the denial was for documentation reasons and may pay out of pocket unnecessarily. Beneficiaries should ask the chiropractor's billing staff whether the AT modifier was applied if a claim is denied.

Mistake four: confusing limiting charge with retail price

Non-participating chiropractors who do not accept assignment can charge up to the limiting charge (115% of non-par fee schedule). They CANNOT charge their full retail rate to Medicare beneficiaries. Beneficiaries should ask the chiropractor what the limiting charge is and refuse to pay more.

Mistake five: signing a private contract without understanding consequences

Opt-out chiropractors require a private contract that waives Medicare coverage for two years. Beneficiaries who sign without understanding may face full out-of-pocket charges. Beneficiaries should never sign without reading the contract carefully and considering alternatives.

Mistake six: expecting coverage for extraspinal manipulation

CPT 98943 (extraspinal CMT) is statutorily excluded. Manipulation of the shoulder, hip, or knee by a chiropractor is not covered, even if medically appropriate.

Mistake seven: confusing chiropractor PT with physical therapist PT

Physical therapy services furnished by a chiropractor (even those that look identical to PT) are NOT covered. PT must be furnished by a qualified physical therapist under 42 CFR 410.59-60 to be covered by Medicare. The distinction is the provider, not the service.

Mistake eight: assuming maintenance therapy is covered after acute treatment

Once maximum therapeutic benefit is reached, additional visits become maintenance therapy. Maintenance is not covered. The chiropractor should advise the beneficiary when the treatment plan transitions to maintenance and should obtain an ABN before continuing to bill.

Mistake nine: assuming Medicare Advantage covers more by default

MA plans cover what Original Medicare covers but may add supplemental benefits. Not all MA plans add supplemental chiropractic benefits. Beneficiaries should read the plan's Evidence of Coverage and compare plans before enrolling.

Mistake ten: not obtaining ABN before non-covered services

For services likely to be non-covered (extraspinal manipulation, maintenance therapy, x-rays), the chiropractor should obtain a signed ABN. Without ABN, the chiropractor cannot bill the beneficiary if Medicare denies. Beneficiaries who receive a bill for a non-ABN'd non-covered service can dispute it.

Mistake eleven: confusing chiropractor with osteopathic physician

Doctors of osteopathic medicine (D.O.) are physicians under Section 1861(r)(1) and can bill for the full range of physician services including osteopathic manipulative treatment (OMT) under CPT 98925-98929. OMT by a D.O. is covered. CMT by a D.C. is covered only with the Section 1861(r)(5) limitations.

Mistake twelve: not appealing denials

Chiropractic claims denied for documentation deficiencies can often be reopened with additional documentation. Beneficiaries have appeal rights through redetermination, reconsideration, ALJ, MAC, and federal court. The first level (redetermination) must be filed within 120 days of the initial denial notice.

Mistake thirteen: not asking about assignment before treatment

Beneficiaries should always ask whether the chiropractor accepts Medicare assignment BEFORE treatment begins. Asking after the fact may result in unexpected bills. Participating chiropractors are listed at medicare.gov/care-compare.

Mistake fourteen: assuming Medigap fills all cost-sharing gaps

Medigap covers the 20% Part B coinsurance for COVERED services only. Medigap does NOT pay for non-covered services (x-rays ordered by a chiropractor, examinations, extraspinal manipulation, maintenance therapy). Medigap also does NOT pay balance billing above the Medicare approved amount.

Resources Brevy connects you with

At Brevy, we maintain comprehensive resources at brevy.com to help Georgia families understand Medicare coverage limitations and make informed decisions about chiropractic care and other narrowly defined Part B benefits. The compromise codified at Section 1861(r)(5) in 1972 has shaped how millions of Medicare beneficiaries experience chiropractic care, and Georgia's 3,500 licensed chiropractors operate within both state scope-of-practice rules and Medicare's narrow coverage parameters. Understanding the difference is the key to avoiding the unexpected out-of-pocket costs that frustrate beneficiaries every day.

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Does Medicare cover chiropractic care?

Medicare Part B covers ONE chiropractic service: manual manipulation of the spine to correct a subluxation. Section 1861(r)(5) of the Social Security Act and 42 CFR 410.22 limit coverage to this single service. Medicare does NOT cover any other chiropractor service: not examinations, not x-rays, not physiotherapy, not acupuncture, not massage, not nutritional counseling, not maintenance care.

What is a subluxation?

NCD 240.1.3 defines subluxation as a motion segment in which alignment, movement integrity, or physiologic function of the spine is altered, although contact between joint surfaces remains intact. This is the chiropractic profession's clinical definition adopted by CMS.

How is a subluxation documented for Medicare?

Two methods are accepted under NCD 240.1.3:

1. X-ray showing visible misalignment (taken within 12 months before or 3 months after start of treatment)
2. Physical examination documenting at least 2 of 4 PART criteria (Pain, Asymmetry, Range-of-motion, Tissue tone), one of which must be Asymmetry or Range-of-motion

What does PART stand for?

PART is the four-criterion physical examination standard:

• P ain or tenderness
• A symmetry/misalignment
• R ange of motion abnormality
• T issue/tone changes

What is the AT modifier and why does it matter?

The AT (Active Treatment) modifier was established by CMS Change Request 3449 effective October 1, 2004. It is required on every Medicare-billed chiropractic claim. The chiropractor uses the AT modifier to certify that the service represents active or corrective treatment, not maintenance care. Claims without the AT modifier are automatically denied as maintenance therapy.

What is the difference between active treatment and maintenance therapy?

Active treatment addresses an acute or exacerbated condition and produces measurable improvement. Maintenance therapy maintains the status quo or prevents recurrence after maximum therapeutic benefit has been reached. Medicare covers active treatment; Medicare does NOT cover maintenance therapy.

Are chiropractor-ordered x-rays covered?

No. 42 CFR 410.22(b) explicitly excludes x-rays from coverage when ordered or performed by a chiropractor. The same x-ray ordered by an M.D. or D.O. would be covered under the diagnostic radiology benefit, but x-rays ordered by a D.C. are statutorily excluded.

Are chiropractor examinations covered?

No. Office visits, consultations, and examinations by chiropractors are not covered. 42 CFR 410.22(b) excludes them.

Are nutritional supplements recommended by chiropractors covered?

No. Nutritional supplements are not covered by Medicare regardless of who recommends them. 42 CFR 410.22(b) further excludes nutritional services when ordered by chiropractors.

What CPT codes are used for chiropractic services?

• CPT 98940: CMT, spinal, 1-2 regions (covered)
• CPT 98941: CMT, spinal, 3-4 regions (covered)
• CPT 98942: CMT, spinal, 5 regions (covered)
• CPT 98943: CMT, extraspinal, 1 or more regions (NOT COVERED)

What is the difference between CPT 98941 and 98942?

CPT 98941 covers manipulation of 3-4 spinal regions (e.g., cervical + thoracic + lumbar). CPT 98942 covers all 5 spinal regions (cervical + thoracic + lumbar + sacral + pelvic). The chiropractor codes based on regions actually manipulated and documented.

What does CPT 98943 cover and why does Medicare not pay?

CPT 98943 covers extraspinal manipulation (shoulder, hip, knee, rib, abdomen). Medicare does not pay because Section 1861(r)(5) limits coverage to manual manipulation of the SPINE. Extraspinal regions are not part of the spine and are therefore statutorily excluded.

How much does Medicare pay for chiropractic manipulation?

Approximate 2026 Georgia payments under the Physician Fee Schedule:

• CPT 98940: $30-33 (Medicare pays 80%, beneficiary pays 20%)
• CPT 98941: $42-46 (Medicare pays 80%, beneficiary pays 20%)
• CPT 98942: $54-58 (Medicare pays 80%, beneficiary pays 20%)

What is the 2026 Part B deductible?

$257. The beneficiary pays the first $257 of approved charges each calendar year. After the deductible is met, Medicare pays 80% and the beneficiary pays 20% of approved amounts.

Does Medigap cover the 20% chiropractic coinsurance?

Yes. All standardized Medigap plans cover the 20% Part B coinsurance for covered services. Plan G (most popular for new enrollees) covers the 20% after the $257 deductible. Plan F (grandfathered for those enrolled before 2020) covers both deductible and coinsurance.

Does Medigap cover non-covered chiropractor services?

No. Medigap covers Medicare-approved cost-sharing only. Medigap does NOT pay for x-rays, examinations, extraspinal manipulation, or maintenance therapy. The beneficiary pays these costs out of pocket.

What is the limiting charge?

The limiting charge is 115% of the Medicare non-participating fee schedule amount. Non-participating chiropractors who do not accept assignment can charge up to the limiting charge but no more. The beneficiary pays the chiropractor up to the limiting charge and receives Medicare reimbursement of 80% of the non-par amount.

What does it mean if a chiropractor has opted out of Medicare?

Opt-out chiropractors have filed an affidavit with the Medicare Administrative Contractor stating they will not accept Medicare payment for any service for two years. Opt-out chiropractors require a private contract before furnishing services. Medicare pays nothing and Medigap pays nothing for services from opt-out chiropractors.

Can Medicare Advantage cover more than Original Medicare?

Yes. Medicare Advantage plans must cover everything Original Medicare covers (manual spinal manipulation) and may add supplemental benefits including coverage of examinations, x-rays, extraspinal manipulation, additional visits, and lower cost-sharing (typically $20-30 copay instead of 20% coinsurance).

How do I find a participating Medicare chiropractor in Georgia?

Use medicare.gov/care-compare and filter for chiropractor specialty and accepts Medicare assignment. Call Medicare 1-800-MEDICARE. Ask any chiropractor's office directly. Confirm participation status before each visit (status can change).

Is telehealth chiropractic covered?

No. Chiropractors are not eligible distant-site practitioners under Section 1834(m) or 42 CFR 410.78. Spinal manipulation requires hands-on physical contact and cannot be furnished via telehealth.

Are chiropractic services in Medicare Advantage plans always cheaper?

Not always. Beneficiaries should compare premium costs, copay structures, network restrictions, prior authorization rules, and annual visit limits. Some MA plans with chiropractic supplemental benefits have higher premiums than Original Medicare + Medigap. Run the math for expected utilization.

Can I appeal a denied chiropractic claim?

Yes. The standard Medicare appeals process applies: redetermination by MAC (within 120 days), reconsideration by Qualified Independent Contractor (within 180 days), Administrative Law Judge hearing (if ≥$190 amount in controversy in 2026), Medicare Appeals Council review, federal District Court (if ≥$1,900 amount in controversy).

How do I file a complaint about a Georgia chiropractor?

For licensure or scope violations: Georgia Board of Chiropractic Examiners, 478-207-2440. For Medicare billing fraud: Medicare 1-800-MEDICARE or HHS OIG hotline 1-800-HHS-TIPS. For consumer protection issues: Georgia Office of the Attorney General Consumer Protection Division, 404-651-8600.

Who can help me with Medicare chiropractic coverage questions in Georgia?

GeorgiaCares (the State Health Insurance Assistance Program) provides free Medicare counseling: 1-866-552-4464. Atlanta Legal Aid (404-377-0701) and Georgia Legal Services (1-800-498-9469) provide free legal assistance for low-income beneficiaries with appeals and coverage disputes. :::

Disclaimers

This guide is provided for educational purposes by Brevy. It is not legal, medical, billing, or coverage advice. Federal regulations at 42 CFR 410.21, 42 CFR 410.22, and NCD 240.1.3 are the authoritative sources for Medicare chiropractic coverage requirements. Section 1861(r)(5) of the Social Security Act is the underlying statutory authority. Coverage determinations are made by the Medicare Administrative Contractor (Palmetto GBA in Jurisdiction J for Georgia) based on documentation submitted with each claim. For specific coverage questions, beneficiaries should contact Medicare at 1-800-MEDICARE, Palmetto GBA at 1-877-567-9230, or GeorgiaCares SHIP at 1-866-552-4464.

Beneficiaries enrolled in Medicare Advantage plans should consult their plan's Evidence of Coverage and member services to understand specific chiropractic supplemental benefits, network requirements, prior authorization rules, and cost-sharing. MA chiropractic benefits vary substantially across plans and can change year over year.

Chiropractor licensure and scope of practice in Georgia is governed by O.C.G.A. §43-9. The Georgia Board of Chiropractic Examiners (478-207-2440) is the authoritative source for licensure questions, scope of practice clarifications, and complaints about chiropractor conduct.

Coverage rules and payment amounts described in this guide reflect federal Medicare policy in effect as of May 2026 and may change through future CMS rulemaking, congressional action, or Medicare Administrative Contractor local coverage determinations. Beneficiaries should verify current rules at the time of service.

::: cta Contacts for Georgia Medicare Chiropractic Services

• DCH Medicaid Member Services: 1-866-211-0950
• Medicare: 1-800-MEDICARE (1-800-633-4227)
• Palmetto GBA Jurisdiction J (Medicare Administrative Contractor): 1-877-567-9230
• GeorgiaCares SHIP: 1-866-552-4464
• Georgia Board of Chiropractic Examiners: 478-207-2440
• Georgia Chiropractic Association: 770-723-1100
• American Chiropractic Association: 703-276-8800
• Social Security: 1-800-772-1213
• HHS OCR: 1-800-368-1019
• HHS OIG Fraud Hotline: 1-800-HHS-TIPS (1-800-447-8477)
• Medicare Rights Center: 1-800-333-4114
• Center for Medicare Advocacy: 1-860-456-7790
• Kepro QIO: 1-844-455-8708
• Atlanta Legal Aid: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469
• 211 Georgia: 211
• Eldercare Locator: 1-800-677-1116
• VA Benefits: 1-800-827-1000
• Georgia Department of Public Health: 404-657-2700
• Georgia Office of the Attorney General Consumer Protection: 404-651-8600 :::