X-Rays: Denied for Chiropractors
Denial Reason, Reason/Remark Code(s)
- PR-170: Payment is denied when performed/billed by this type of provider
- CPT codes: 70000 through 79999
Medicare coverage of services performed by chiropractors is limited to treatment by means of manual manipulation of the spine to correct a subluxation, provided such treatment is legal in the state where performed. All other services furnished or ordered by chiropractors are not covered.
If a chiropractor orders, takes or interprets an X-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the X-ray can be used for documentation. However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor.
Services such as office visits (evaluation and management services), diagnostic studies, physical therapy and other services rendered by chiropractors are not required to be submitted for coverage consideration by the Medicare program. The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. If a Medicare beneficiary believes a service may be covered or requests a formal Medicare determination for consideration by a supplemental plan, the provider must submit a claim.
- To submit a claim for a non-covered service by a chiropractor, use HCPCS modifier GY to indicate that the service is statutorily excluded from coverage
- You may submit both covered and non-covered services on the same claim
Submitting Non-covered Services for Denial Purposes
If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
- CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the 'old' Notice of Exclusion from Medicare Benefits (NEMB) language and may be used right away. Use of the revised ABN is optional for services that are excluded from Medicare benefits. Access revised ABN and other background information from the CMS website.
- If you have obtained a valid ABN for excluded services for services provided on or after March 1, 2009, submit claims for this service with HCPCS modifier GY. Refer to the Palmetto GBA Modifier Lookup Tool for information on HCPCS modifier GY.
- CMS Medicare Benefit Policy Manual, Chapter 15, Section 30.5 (Chiropractic Services) (PDF, 1.18 MB)
- For detailed information on using X-rays to determine subluxation, see Section 240.1.2 of this manual