Chiropractic E/M With CMT: When Modifier 25 Holds Up

A chiropractor performs chiropractic manipulative treatment (CMT) and, in the same visit, evaluates a patient for something beyond that day’s adjustment. Is that evaluation billable as a separate office visit? The answer depends on three frameworks that ranking pages tend to blur: the CPT/NCCI bundling rule for any 000-day global procedure, Medicare’s statutory exclusion of everything a chiropractor does except spinal manipulation, and commercial payer policies that don’t all say the same thing.

CMT codes 98940-98942 carry a 000-day global period, bundling the exam behind the decision to adjust into the CMT payment under NCCI’s minor-procedure rule rather than making it separately billable. Medicare pays no chiropractic E/M under any circumstance, with or without modifier 25, because the statute recognizes a chiropractor as a “physician” only for spinal manipulation. Commercial payers diverge: UnitedHealthcare requires modifier 25 on a same-day E/M that is significant and separately identifiable, while Aetna’s chiropractic policy sets a documented-improvement expectation but never mentions modifier 25. A CMS proposal for 2027 would pay the lower-valued of a same-day E/M and global-period procedure at 50 percent on Medicare physician claims, though it isn’t final and doesn’t mention chiropractic.

Current as of September 2026.

Can a chiropractor bill an exam and an adjustment on the same day?

Chiropractic manipulative treatment (98940, 98941, 98942) carries a 000-day global period on the Medicare Physician Fee Schedule, confirmed in the October 2026 RVU file release (RVU26D, released 08/26/2026). That makes CMT a “minor surgical procedure,” and the NCCI Policy Manual, Chapter XI (Revision Date 1/1/2026) states the consequence directly:

“In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. … The fact that the patient is ‘new’ to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”

That closes off the most common workaround: billing an E/M for every new patient regardless of what the visit involved. NCCI Chapter I defines modifier 25, per the CPT codebook, as a “Significant, Separately Identifiable Evaluation and Management Service … on the Same Day of the Procedure or Other Service,” adding that it “may be related to the same or different diagnosis as the other procedure(s).” The question isn’t new versus established, or which diagnosis is billed; it’s whether the visit did more than decide to adjust the spine.

Is there a chiropractic evaluation CPT code?

No. CPT has no code labeled “chiropractic evaluation.” When a DC performs an office evaluation, it’s billed with the same office/outpatient E/M codes 99202-99215 every other qualified health care professional uses; the AMA’s 2023 E/M guidelines note that each level “may be used by all physicians or other qualified health care professionals,” with no specialty carve-out.

For a Medicare patient, that rarely matters, since Medicare pays no chiropractic E/M under any modifier (below); the assessment work is instead built into the CMT service itself and documented as part of that visit (see the Medicare chiropractic billing guide for what that record must contain). For commercial plans that reimburse a DC’s office E/M, 99202-99215 is selected the way covered below.

Does Medicare pay chiropractors for 99213?

No, and not because of modifier 25. The exclusion is statutory. 42 U.S.C. 1395x(r)(5) defines a chiropractor as a “physician” under Medicare only “with respect to treatment by means of manual manipulation of the spine (to correct a subluxation).” The Medicare Benefit Policy Manual, Chapter 15, §30.5 (Rev. 13889, issued 07-30-26) makes that the entire scope: “All other services furnished or ordered by chiropractors are not covered,” and §240.1.1 repeats it: “No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered.” An office visit is such a service, outside the benefit regardless of coding or modifiers.

Noridian, the Part B MAC for Jurisdiction F, confirms this operationally: “Services such as office visits (evaluation and management services) … are not required to be submitted for coverage consideration by the Medicare program” (Chiropractic Claim Submission Requirements, Nov. 18, 2024). If billed anyway, append “modifier GY to indicate that the service is statutorily excluded from coverage.” That’s different from the AT/GA framework used for maintenance CMT, covered in the Medicare chiropractic billing guide: GY flags a service that is “statutorily excluded from coverage,” while, in Noridian’s words, “Modifier GA indicates that the provider expects that Medicare will deny a service as not reasonable and necessary and that an ABN has been signed by the patient.”

The patient is financially responsible regardless. CMS’s guidance states: “You don’t need to notify the patient before you provide an item or service we never cover … you may issue a voluntary notice … Issuing the notice voluntarily doesn’t affect financial liability” (MLN006266). That voluntary notice is an ABN with GX appended, covered in full in the ABN modifiers guide; practices bill GY with or without voluntary GX, or simply collect from the patient directly.

How commercial payers treat modifier 25 with CMT

Medicare’s answer is uniform. Commercial payers vary, and not every payer’s chiropractic policy addresses the question at all.

UnitedHealthcare’s logic runs close enough to Medicare’s NCCI framework that the same discipline, documenting a reason for the visit beyond the adjustment, applies before billing modifier 25 on a UHC claim. Aetna’s CPB and UHC’s manipulative-therapy policy simply don’t speak to it, which leaves the plan’s reimbursement policy and contract terms to control.

One more NCCI rule matters for commercial claims that follow Medicare’s edit logic, though it isn’t about E/M: NCCI Chapter XI, Section S states that “[p]hysical medicine and rehabilitation services described by CPT codes 97112, 97124 and 97140 are not separately reportable when performed in a spinal region undergoing CMT,” though in a different region they may take modifier 59 or XS, the same logic as the therapy NCCI edits.

What documentation makes the E/M separately identifiable

The E/M and the procedure both have to earn their place in the record. Ch. 12, §30.6.6.B states it as a joint requirement: “Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented … to support the claim for these services.” One note covering both, with no distinction between the exam behind that day’s adjustment and something else evaluated, meets that standard for neither.

For Medicare, Noridian’s documentation guidelines (last updated Apr. 2, 2025) already require every subsequent CMT visit to show a “Review of chief complaint …,” “Changes since last visit - just stating increased or decreased pain is not sufficient,” an “Exam of area of spine involved in diagnosis …,” and an “Assessment of change in patient condition since last visit ….” Since Medicare never pays the E/M regardless, this supports the CMT claim, not a separate visit charge.

Only one fetched commercial policy sets a documented interval for re-evaluation. Aetna’s CPB 0107 states: “Improvement in member’s condition should be documented within the initial 2 weeks of chiropractic care,” and “[i]f no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.” Neither UnitedHealthcare nor Noridian sets a fixed re-exam interval; treat the 2-week/30-day cadence as Aetna-specific.

Why modifier 25 draws review on chiropractic claims

Modifier 25 has its own review process written into the Claims Processing Manual. Ch. 12, §30.6.6.B describes the trigger: “When an A/B MAC (B) has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier ‘-25’ compared to other physicians … the A/B MAC (B) may impose prepayment screens or documentation requirements for that provider or group.” UnitedHealthcare’s E/M policy describes a comparable commercial practice: “A providers’ level of care escalation data … may be compared to their historical data and to peer data.”

Neither is a statistic; both describe a review process a MAC or payer can activate. Either way, a pattern of modifier 25 on most or all CMT visits, without documentation distinguishing the E/M from that day’s manipulation, is exactly what these processes are built to find.

How to pick the E/M level for a chiropractic visit

Where an E/M is billable, the code is selected the same way for a DC as for any other provider. UnitedHealthcare’s E/M policy states: “Except for CPT codes 99281-99285, providers may choose the appropriate E/M level of care based on either Time or Medical Decision Making (MDM).” The AMA’s 2021 E/M guideline changes set the codes:

MDM level is set by meeting or exceeding two of three elements (problems addressed, data reviewed, and risk), per the AMA’s MDM table; UnitedHealthcare’s policy echoes the standard: “When determining the level of MDM, two of the three elements for that level must be met or exceeded.”

Time works differently for a chiropractic visit than it might look on paper. The AMA’s guideline defines time as “the total time on the date of the encounter” that “does not include any time spent in the performance of other separately reported service(s)”: CMT minutes never count toward E/M time. UnitedHealthcare echoes it: time “may not include … additional distinct service procedures provided the same day as the evaluation and management service.” A time-based level that folds in CMT minutes overstates the visit.

New-versus-established status follows the general rule in the AMA guidelines: a new patient “has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

The CY2027 proposal: same-day E/M paid at 50 percent

CMS’s CY 2027 Medicare Physician Fee Schedule proposed rule (fact sheet, July 14, 2026) proposes cutting payment for the lower-valued service when the same physician (or a physician in the same practice) furnishes a separately identifiable office/outpatient E/M and a 0-, 10-, or 90-day global procedure on the same day: “The most expensive service (either surgical or E/M visit) would be paid at 100% and all other surgical procedure(s) or E/M visit(s) furnished on the same day would be paid at 50%.” The proposed rule text (CMS-1848-P, July 16, 2026) gives an example with 99212, 11300, and 11301: “CPT code 11301 will be paid at 100 percent … and CPT code 11300 and the payment for CPT code 99212 will both be reduced by 50 percent.” CMS invites comment on “whether it would be more appropriate to match a different MPPR value, such as 25 percent.” The text does not mention chiropractic.

This is a proposal, not a final rule; the comment period closed September 14, 2026. By statute, 42 U.S.C. 1395w-4(b)(1) requires that “the Secretary shall establish, by regulation, fee schedules” “[b]efore November 1 of the preceding year,” so a final rule is expected before then, effective January 1, 2027 if adopted.

Medicare pays no chiropractic E/M under any modifier, so this changes nothing for a DC’s Medicare claims directly. The exposure, if any, is commercial: UnitedHealthcare’s Global Days policy is built on the same global-days framework CMS uses, so payers that mirror that logic could follow suit if the rule is finalized. That’s an inference, not something any payer has announced. See the CY2027 fee schedule guide for the same proposal’s effect on therapy billing.

Checklist

• Don’t bill an E/M for the exam behind the decision to adjust; it’s bundled into CMT under NCCI’s minor-procedure rule.
• Never bill Medicare for a chiropractic E/M under any modifier; it’s statutorily excluded, not modifier-dependent.
• Use GY (and voluntary GX with an ABN) on a Medicare E/M line, not GA/GZ, which belong to the maintenance-CMT framework.
• Document the E/M and CMT as two distinct services before appending modifier 25 on a commercial claim.
• Confirm the payer’s policy addresses modifier 25 with CMT at all; UHC’s Global Days policy does, its Manipulative Therapy policy and Aetna’s CPB 0107 don’t.
• Select the E/M level by MDM or by total time, and never count CMT minutes toward E/M time; watch for the CY2027 final rule before assuming any commercial change.

Keeping Medicare’s statutory exclusion and a commercial payer’s modifier 25 rule from colliding on the same fee schedule is a systems problem before it’s a documentation problem. PrismEHR lets organizations define their own billing rules, enforced at documentation and reinforced at claim creation: a rule that keeps 99xxx E/M lines off Medicare CMT claims (or forces GY onto them) while allowing them normally on commercial claims, and a rule that won’t let modifier 25 attach until the E/M note is documented separately from the CMT note. See how it fits chiropractic practices, or read the Medicare chiropractic billing guide for the CMT rules this post builds on.