Even the proficient chiropractic professionals encounter significant financial challenges due to errors in billing and coding procedures, which could be avoided. The oversight of simple billing mistakes leads to delayed payments, which causes disruptions in cash flow, an increase in claim denials, and a damaging reputation by inviting legal examinations or audits.

Chiropractic billing mistakes send red flags to insurance companies, signaling patterns that suggest overbilling or non-compliance. The appearance of repeated red flags will trigger an investigation against your practice, regardless of your intent.

This blog will provide an understanding of common chiropractic billing errors and their avoidance methods to secure your clinic’s revenue stream.

What Are Chiropractic Billing Red Flags?

Red flags in chiropractic billing are warning signs that indicate potential coding errors, overuse of procedures, or poor documentation practices. Such errors create insurance company doubts about reimbursements and might trigger extensive investigations which could result in fraud inquiries.

Whether it’s submitting inaccurate codes, billing for unnecessary treatments, or lacking proper documentation, these missteps can put your practice’s revenue and credibility at risk.

Major Chiropractic Billing Mistakes That Hurt Revenue

The following are the most damaging billing and coding mistakes chiropractors make, with the ways to deal with them:

1. Upcoding

Sometimes, healthcare providers submit insurance claims for more advanced medical procedures than the ones they genuinely performed during the patient visit, known as upcoding. In chiropractic care, this often involves spinal manipulation CPT codes such as:

• 98940 – One to two spinal regions
• 98941 – Three to four regions
• 98942 – Five regions

For example, if you treat three regions but mistakenly bill for five, that’s considered upcoding—even if unintentional. Insurers view this as overbilling, which can lead to audits, denied claims, or penalties.

How to prevent it:

• Ensure precise documentation in SOAP notes, clearly identifying the number of spinal areas treated.
• Utilize practice management software that links CPT codes to clinical notes.
• Conduct regular internal audits to identify and correct any coding discrepancies.

2. Overusing Maintenance Therapy Codes

Insurance providers typically reimburse only for medically necessary care. If a patient continues care after recovery or stabilization, that’s considered maintenance therapy which insurers don’t cover. In fact, consistently billing for maintenance visits using codes like 98940–98942 without valid medical necessity is a red flag.

How to prevent it:

• Justify every visit with clear clinical progress documented in SOAP notes.
• Use objective outcome measures (e.g., range-of-motion tests) to validate necessity.
• Set patient expectations by explaining when care transitions from reimbursable to wellness-based.

3. Repeating the Same Diagnosis for Every Patient

Using identical ICD-10 codes across different patient records, regardless of symptoms or progress—can trigger payer suspicion. A repeated pattern of diagnoses like M99.01 (cervical segmental dysfunction) or M54.5 (low back pain) without variation suggests lazy documentation or canned entries.

How to prevent it:

• Avoid copy-pasting diagnoses from previous visits.
• Evaluate each patient’s unique condition and code accordingly.
• Double-check SOAP notes to ensure individualized assessments.

4. Missing or Incomplete Documentation

Without complete documentation to support billed procedures, your claims can be denied. Poor documentation often includes:

• Missing treatment goals
• No objective findings
• Copy-pasted or outdated notes

How to prevent it:

• Train your staff to include measurable patient data (e.g., pain scale, mobility).
• Use digital note systems that prompt required fields.
• Implement regular reviews of clinical records to ensure compliance.

5. Duplicate Billing

Duplicate billing refers to submitting the same charge more than once. Whether it’s resubmitting a claim accidentally or billing two codes for the same procedure, insurers view this as a red flag, sometimes even as fraud.

How to prevent it:

• Use the latest software and tools that detect and flag potential duplicate entries.
• Implement a claim review process before submission.

6. Inaccurate or Outdated Diagnosis Codes (ICD-10 Errors)

Using the wrong ICD-10 code or failing to update your coding list can lead to denials or payment delays. Common errors include:

• Using vague or non-specific codes
• Pairing diagnosis codes with mismatched CPT codes
• Submitting outdated ICD-10 codes

How to prevent it:

• Keep your coding resources current.
• Match CPT and ICD-10 codes properly to show medical necessity.
• Regularly train your billing team on code updates.

7. Billing for Services Outside Your Scope

Not all services are covered under chiropractic licensure or insurance policies. Billing for massage therapy, acupuncture, or dry needling without checking state laws or insurance rules can get you flagged for unlicensed practice.

How to prevent it:

• Only bill for services permitted under your chiropractic license.
• Verify patient insurance before delivering non-standard services.
• Stay informed of both state regulations and payer policies.

8. Lack of Proof for Medical Necessity

Insurance carriers won’t pay for services that lack clinical justification. Billing repeatedly for the same procedure without showing measurable improvement may result in denials or audits.

How to prevent it:

• Document patient progress with metrics like pain levels or flexibility.
• Make clear distinctions between wellness and medically necessary care.
• Notify patients when care moves beyond coverage so they’re prepared for out-of-pocket expenses.

9. Skipping Insurance Verification Before Appointments

Assuming a patient’s insurance covers your services without verifying in advance is risky. In fact, coverage varies significantly between plans and payers, and mistakes can leave patients with unexpected bills and your clinic with unpaid claims.

Common oversights:

• Skipping eligibility checks
• Overlooking exclusions
• Missing prior authorization requirements

How to prevent it:

• Implement a pre-treatment insurance verification system.
• Confirm benefits, limitations, and authorization needs ahead of each visit.

Conclusion

Dealing with the complex world of chiropractic billing and coding can be a daunting task for many providers. Your practice needs to follow both private insurance carrier standards and Medicare requirements in order to maintain a smooth revenue cycle and practice financial stability. Even minor coding or documentation errors will lead to delayed payments and denied claims, together with possible audits of your work. Therefore, don’t let simple mistakes sabotage your revenue. In fact, your billing success depends heavily on collaboration with expert professionals at Info Hub Consultancy Services who focus on chiropractic billing and coding services.

FAQs

1. What CPT codes do chiropractors commonly use?
Chiropractors perform spinal manipulations using CPT codes 98940–98942, together with therapeutic procedures billed as CPT codes 97110, 97112 and 97140.

2. Does insurance cover chiropractic adjustments?
Insurance coverage depends on which plan the policyholder has. Medical necessity adjustments receive coverage benefits from insurance while wellness or maintenance adjustments typically do not receive coverage.

3. What is CPT code 97110 used for in chiropractic billing?
Chiropractors bill CPT 97110 to cover therapeutic exercises that require one-on-one training for strength improvement and flexibility and endurance development purposes.

4. Why are chiropractic claims denied?
Medical claims get denied primarily due to the use of outdated codes with insufficient medical records, absence of medical necessity, and inappropriate billing of uncovered services.