What is the PART documentation requirement for chiropractic Medicare billing?

Medicare requires documentation of PART findings for spinal manipulation: Pain or tenderness at the manipulation site, Asymmetry or misalignment by palpation or visual inspection, Range of motion abnormality, and Tissue/Tone changes (muscle spasm, edema, texture). At least 2 of 4 elements must be present and documented for each region manipulated to support medical necessity.

What CPT codes are used for chiropractic spinal manipulation?

Spinal manipulation codes: 98940 (1-2 spinal regions), 98941 (3-4 spinal regions), 98942 (5 spinal regions). Regions are: cervical, thoracic, lumbar, sacral, and pelvic. Document each region adjusted and the subluxation findings. Extraspinal manipulation uses 98943. E/M services (99201-99215) can be billed separately with modifier 25 if a significant, separately identifiable evaluation is performed.

How do I document a subluxation for chiropractic billing?

Document the specific spinal segment(s) with subluxation (e.g., C5, T4-T6, L4), objective findings supporting the subluxation (PART elements), the subluxation's relationship to the patient's symptoms, and the clinical rationale for manipulation. Use standard spinal listing notation if your practice uses it. Medicare requires subluxation demonstrated by X-ray or physical exam.

What is the Medicare requirement for chiropractic treatment plans?

Medicare requires: specific diagnosis with ICD-10 code, treatment frequency and duration, short-term and long-term treatment goals, date of initial treatment, and expected functional improvement. Document re-evaluations showing progress toward goals. Maintenance care (preventing deterioration without expected improvement) is generally not covered by Medicare.

When can a chiropractor bill for an evaluation in addition to manipulation?

Bill E/M codes (99202-99215) separately only when a significant, separately identifiable evaluation is performed beyond the pre-manipulation assessment. Use modifier 25. Examples: new patient comprehensive history and exam, re-evaluation with significant change in condition, or evaluation of a separate problem. Document distinct HPI, exam, and MDM for the E/M service.

Chiropractic Exam Template - SOAP Note & Subluxation

Chiropractic — New Patient Exam Template

Rehabilitation Chiropractic Updated: 1/4/2026

The Chiropractic New Patient Exam Template is designed for chiropractors performing initial evaluations. This template documents the 'PART' requirements for Medicare (Pain/Tenderness, Asymmetry, ROM, Tissue Tone), analysis of spinal subluxations, orthopedic testing, and calculation of a care plan. Includes sections for spinal listing and adjustment technique planning. Ideal for chiropractic clinics.

Patient Information

Date: [Date]
Visit Type: Initial Exam
Diagnosis: [ICD-10]

Subjective (History)

Chief Complaint: [Primary spinal region] Onset: [Date/Mechanism] Palliative/Provocative: [Better/Worse with...] Quality: [Sharp, dull, radiating] Radiation: [Location] Severity: [0-10 VAS] Timing: [Constant, intermittent]

Objective (Examination)

Vitals: BP [Value], HR [Value] Visual Assessment:

Posture: Head tilt / High shoulder / High hip (L/R)
Gait: Normal / Antalgic / Abnormal

P.A.R.T. Analysis (Medicare Requirement):

1. Pain/Tenderness: [Location and severity/grade]
2. Asymmetry/Misalignment: [Spinous deviation, static palpation]
3. Range of Motion:

Cervical: Flex [X], Ext [X], Rot L [X]/R [X], Lat Flex L [X]/R [X]
Lumbar: Flex [X], Ext [X], Rot L [X]/R [X], Lat Flex L [X]/R [X]
Pain with motion: [Yes/No]

4. Tissue/Tone: [Spasm, edema, trigger points - Location]

Orthopedic/Neurologic Tests:

Straight Leg Raise: Pos / Neg
Kemp's Test: Pos / Neg
Cervical Compression: Pos / Neg
DTRs: +2/4 (Normal) / Hyper / Hypo

Spinal Listings / Subluxation Complex:

Cervical: [Segment(s) - e.g., C1, C5]
Thoracic: [Segment(s) - e.g., T4-T6]
Lumbar: [Segment(s) - e.g., L4, L5]
Pelvis: [Sacrum, Ilium]

Assessment

Patient demonstrates functional deficit and spinal subluxation at levels [Levels] consistent with [Diagnosis].
Prognosis: Good for symptom relief and functional restoration.

Plan

Treatment Frequency: [X]x/week for [X] weeks. Adjustments (98940/98941/98942):

Technique: Diversified / Activator / Drop table
Regions: Cervical / Thoracic / Lumbar / Sacral / Pelvic

Therapies:

Electrical Stimulation: [parameters]
Traction: [parameters]
Soft Tissue Mobilization: [Region]

Home Instructions:

Ice/Heat application
Home exercises: [Stretches described]
Ergonomic advice

Chiropractic — New Patient Exam Template

Template

Patient Information

Subjective (History)

Objective (Examination)

Assessment

Plan

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