2026 Medicare Chiropractic Billing & Regulatory Updates

If you bill Medicare in your chiropractic clinic, 2026 is not a year to be overlooked. Medicare is tightening documentation requirements, updating CPT and ICD-10 codes, and sharpening its focus on active treatment rules. 

Chiropractic services already face a 33.6 percent improper payment rate, and most of this is due to incomplete or inadequate documentation.

Here is what I want you to take from this guide:

• What Medicare still covers
• The CPT changes around E/M, telehealth, time-based visits, and newer tech codes
• The 2026 ICD-10 diagnosis updates that affect the back, neck, and related conditions
• The significant compliance risks in 2026, including the AT modifier, proof of active treatment, and same-day E/M plus adjustment rules
• How to update your code library and train your team

I have spent the last decade speaking with chiropractors and clinic administrators who deal with this issue every day. My goal is simple. I want you to feel clear, not stressed, when you hear “Medicare update.”

Let's examine what is changing and how to prepare your clinic so you get paid without a fight.

Understanding 2026 Medicare Rules For Chiropractic Care

Let us start with what has not changed.

Medicare still covers only manual spinal manipulation to correct a subluxation under Part B. That means:

• The service is hands-on spinal manipulation
• The main diagnosis is a spinal subluxation at a specific level
• The care is active treatment for an acute or chronic problem, not maintenance care

That basic picture remains the same in 2026. The pressure point is how clearly you show that in your notes.

Active treatment vs maintenance care

Medicare is very explicit about this. Active treatment is when:

• The patient has a significant neuromusculoskeletal problem
• You expect a reasonable level of improvement
• You have a clear plan with frequency, duration, and goals

Maintenance therapy is when:

• The condition has reached a plateau
• You are mainly trying to prevent decline or keep the patient comfortable
• There is no reasonable expectation of further improvement

Medicare pays for the first group. It does not pay for the second. The official documentation job aid for chiropractic doctors emphasizes this point multiple times and ties it directly to the use of the AT modifier.

In 2026, that line remains unchanged. The guidance on what constitutes active care is more detailed.

Why is documentation pressure going up?

The Medicaid improper payment rate for 2022–2024 was 5.09%, totaling $31.10 billion, down from 8.58% in 2023. However, 79.11% of these payments were due to insufficient documentation.

For chiropractic practices, this highlights the crucial importance of maintaining clear and complete documentation to prevent payment delays or denials. So in 2026, your most significant risk is not “picking the wrong code.” It is failing to show, in your notes, that:

• There is a subluxation
• It is tied to the symptoms
• You have a plan
• The patient is actually improving

If you keep this in your head while you read the rest of this guide, the rest will feel more manageable. You can also review these billing and coding red flags and learn how you can avoid them.

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Related Read: Chiropractor’s Guide to Credentialing with Insurance Companies

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New 2026 CPT Code Changes To Watch

Now, let's discuss CPT. The 2026 CPT code set introduces 288 new codes, 84 deletions, and 46 revisions, resulting in a total of 418 changes throughout the book.

Most of your daily work still sits in 98940–98942. Those codes are not changing. What changes is everything around them.

1. E/M guideline refinements

The focus for 2025–2026 is on refining Evaluation and Management (E/M) codes, with key changes in:

• Clearer rules for time-based coding
• Improved alignment of E/M rules across different settings
• Better integration of telehealth visit codes with standard E/M

For your clinic, this matters when:

• You bill an E/M visit on the same day as an adjustment
• You encounter a new, complex case that requires a higher-level evaluation
• You use the total time to select an E/M level

If you select an E/M level based on time, you must document the specific activities performed during that time. If it's based on decision-making, you'll need to show the complexity. This is the level of detail auditors expect in 2026.

2. AI-assisted and remote monitoring codes

2026 is also the year AI and remote care codes stop being a novelty and become part of the normal CPT set. These include:

• New and expanded codes for remote patient monitoring and remote therapeutic monitoring
• AI and augmented-intelligence codes for diagnostic and decision support services
• Stricter CMS guidelines on how these codes should be documented and billed

While most chiropractic clinics won’t bill these codes directly, they can still impact you when:

• A referring provider uses your notes to justify their own remote monitoring or AI-assisted service
• You are part of a group where other providers bill these codes, and your documentation needs to align with theirs

You don’t need to jump into these codes right away, but you should ensure your documentation is clear and accurate, so other providers and payers can trust it. 

Note:

Although not an AI feature, if you're using Noterro, as you add new codes to your invoices, it will remember and suggest them as you type, making the process smoother and reducing the risk of missing or incorrect codes.

3. Telehealth and time-based rules

Telehealth rules continue to shift as pandemic flexibilities expire. CMS has extended many telehealth flexibilities through September 30, 2025, but has already indicated that location and originating site rules will tighten again thereafter for many non-behavioural services.

At the same time, coding resources highlight:

• New telemedicine E/M service ranges proposed for the 98000–98015 code family for 2026
• Ongoing emphasis on documented total time, including what you actually did in that time

If your clinic uses telehealth for follow-up visits, education, or check-ins that connect to Medicare billing, you will need:

• Clear rules about which codes you will use
• Documented time and service details for those visits
• A way to store those codes separately from in-person services, so your team does not mix them up

Again, the core chiropractic manipulation codes are stable. The risk sits in everything you add around them.

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Bonus read: 8 Must-Have Tools for Running a Modern Chiro Practice

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ICD-10 FY 2026 Diagnosis Updates That Affect Chiropractors

CPT isn’t the only codebook changing; ICD-10 is also undergoing substantial updates. The FY 2026 ICD-10-CM update, effective for discharges and encounters from October 1, 2025, through September 30, 2026, brings:

• 487 new diagnosis codes
• 38 revisions
• 28 deletions

While the standard spinal and extraspinal codes you use daily won’t change, there are more detailed coding requirements for pain, injuries, and comorbid conditions.

New Pain and Injury Detail

The update introduces more precision in several areas:

• Pelvic and suprapubic pain now has specific codes
• Flank pain and tenderness are now distinctly coded
• Abdominal wall and trunk contusions are split by location and type of encounter

For your clinic, that means when a Medicare patient presents with:

• Non-spinal pain in the pelvic or lower abdominal area
• Flank pain related to a fall or soft-tissue injury
• Contusions to the trunk, hip, or groin

You can no longer rely on vague codes. The update provides clearer choices, but it expects you to select the right one each time.

When to Update Superbills and EHR Pick-Lists

The date rules are strict here.

• Use the 2026 ICD-10-CM codes for any visit on or after October 1, 2025
• Older dates of service keep the older codes, even if you submit the claim later

So you have a small window to get ready. I would handle it like this:

1. Pull your current top diagnosis list: Export the ICD-10 codes you use most often in Medicare cases.
   
2. Check those codes against the FY 2026 update: Review the updated ICD-10-CM files to determine which of your codes have been revised or deleted.
   
3. Update your superbills and EHR pick-lists: Remove deleted codes and add new, detailed codes for pain and contusions that you know you will use.
   
4. Walk your team through examples: Take a few recent cases and show how you would code them with the 2026 rules.

If you're using Noterro, you can also create superbills directly within the system. This allows you to update your billing items and diagnosis options in one place, ensuring that your invoices and insurance claims are based on the most up-to-date list, without relying on outdated paper forms or memory-based errors.

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Also Read: 8 Best Chiropractic Billing Software for New Practices (2026 Update)

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Compliance Hot Spots And Modifiers In 2026

Now, let's discuss the aspects of Medicare that still catch chiropractors off guard.

1. AT modifier and maintenance therapy

The AT modifier is still required for Medicare to pay CPT codes 98940, 98941, and 98942 as active treatment. CMS is very clear about this in its documentation checklist for chiropractic doctors. You can follow a few simple rules:

• Use AT only when you are correcting an acute or chronic subluxation
• Do not use AT for maintenance therapy
• Do not assume that AT alone proves medical necessity

Your notes still need to show:

• The subluxation and related symptoms
• The treatment plan
• The patient’s progress

Once the patient reaches a point at which no further improvement is expected, and care becomes supportive, Medicare treats it as maintenance. AT should be removed, and coverage should stop.

2. Documentation proof of active treatment

CMS’s documentation job aid lays out what they expect on both initial and subsequent visits. On initial visits, they expect a complete picture:

• Detailed history, including onset and impact on function
• Exam findings that support the subluxation
• Objective measures that you can repeat later
• A written plan with goals and expected duration

On subsequent visits, they expect you to show:

• Changes since the last visit
• Updated objective findings
• How the patient is moving toward or away from goals

This is not about writing novels. It provides enough detail that, if someone else reads your notes months later, they can see why each visit remains active care.

3. Same-day E/M and adjustment

Same-day E/M and spinal manipulation will stay on Medicare’s radar in 2026. The questions are simple:

• Was there a separate, significant evaluation beyond what you usually do before an adjustment
• Did the visit meet the criteria for the E/M level you billed
• Did your notes make that clear

You should not have to guess here. When you bill an E/M on the same day as a manual adjustment, your notes should read like two pieces of work, not one blended block. That is what auditors look for when deciding if a separate E/M is justified.

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Bonus Read: Maximizing Results through Efficient Claim Processing with Chiro Software

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Operational Impact For Clinics And Admins

Now, let us bring this down to the front desk, the billing team, and your daily workflow.

1. Update your code library and forms

You do not want to be fixing ICD-10 and CPT problems during a Medicare audit.

For 2026, I would:

• Update the diagnosis pick-lists to include the 2026 ICD-10-CM codes for pain, contusions, and comorbidities you frequently see in your practice.
• Review your CPT list for any E/M, telehealth, and digital health codes your clinic uses.
• Refresh paper superbills and any cheat sheets pinned to workstations to reflect the updated codes.

If you're using Noterro, here’s how it helps:

• You can update and manage billing codes directly in the system, ensuring they’re always up to date when generating invoices or claims.
• Insurance billing tools are built into Noterro, handling claims, insurer payments, and direct integrations with clearinghouses like Availity.
• Noterro supports TELUS eClaims for Canadian clinics, streamlining insurance submissions for both US and Canadian practices.

With Noterro, you can:

• Add or adjust billing codes used for invoices and claims with ease.
• Link updated codes to the right insurers and clearinghouses, ensuring compliance across both US and Canadian workflows.

My goal with Noterro has always been the same. You should spend less time wrestling with billing rules and more time caring for patients. When 2026 rules hit, that means getting ahead of code and documentation changes instead of reacting after denials land in your queue.

Related Read: 8 Chiropractic Billing and Insurance Tips Every Clinic Should Follow

2. Train your billing and front desk teams

Your team does not need to memorize every ICD-10 or CPT change. They do need to know where they touch your clinic. I would focus training on:

• The difference between active and maintenance care under Medicare
• When to apply the AT modifier and when not to
• New 2026 diagnosis options that they will see in your software
• How to handle same-day E/M plus adjustment requests from providers

You should also use real examples from your own charts. Pick 5–10 recent Medicare cases and walk through how you would code them on or after October 1, 2025, using the new ICD-10 rules.

Make 2026 The Year You Get Ahead Of Medicare

Medicare is clear, but it’s still a challenge. For chiropractic in 2026, spinal manipulation for subluxation remains the only covered service. Documentation must prove active treatment, not just “patient feels better.” 

The new CPT and ICD-10 updates raise the bar for accuracy, and the AT modifier along with same-day E/M plus adjustment still carry audit risks if your notes don’t back them up.

By updating your codes, improving your documentation, and giving your team the right tools, you can reduce denials and protect your revenue. 

Noterro helps streamline all of this into one system, making Medicare compliance part of your daily workflow.