The Medicare Limiting Fee — Not So Limited for Chiropractors

Understanding the Medicare Part B Limiting Fee in Chiropractic Care

Hot Topics from the KMC University HelpDesk

If your practice is confused about what you can charge Medicare patients, you’re not alone. The Medicare limiting fee causes ongoing uncertainty for many chiropractic teams. But when used correctly, it can be a helpful tool—especially for cash-based practices.

In this HelpDesk video, KMC clears up common misconceptions about the Medicare Part B limiting fee and explains how to stay compliant while protecting your revenue.

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What Is the Medicare Limiting Fee?

The limiting fee is the maximum amount that a non-participating provider—who does not accept assignment—can charge a Medicare patient for a covered spinal adjustment during active treatment. It’s calculated as 115% of the Medicare-approved amount.

If you’re not accepting assignment, you may collect this full amount at the time of service. In fact, that’s what makes the limiting fee strategy so attractive to chiropractors with cash-oriented practices.

What Services Does the Limiting Fee Apply To?

Here’s where it gets tricky: The limiting fee only applies to covered spinal adjustments that are marked with the AT modifier—meaning active treatment.

Some chiropractors mistakenly believe they must apply the limiting fee to all services they offer Medicare patients. That’s incorrect.

For non-covered services—like exams, therapies, and maintenance care—you can charge your actual fee or a properly structured discounted rate (such as those used with ChiroHealthUSA).

Maintenance Care and ABNs

When a patient is receiving maintenance care, you’re allowed to charge your regular fee—as long as you have a properly executed ABN (Advance Beneficiary Notice) in place. Whether you’re charging full fee, offering a 10–15% discount, or using an approved discount program, you’re not bound by the limiting fee in these cases.

What About Medicare Advantage (Part C)?

The rules shift under Medicare Advantage plans. If you’re in-network, you must follow the contracted fee schedule and reimbursement policies for that specific plan. That includes knowing what’s covered and what isn’t. Some PPO or Private Fee-for-Service plans may reimburse for additional services like therapies or exams, while many HMOs do not.

If you’re out-of-network, you may not need to bill the plan at all—but you must verify first. Billing an MA plan when you’re out-of-network could mean you’re agreeing to their fee schedules and restrictions.

Don’t Forget QMB Status

If your patient is a Qualified Medicare Beneficiary (QMB), you cannot collect anything at the time of service—even if you’re non-participating. These patients’ services must be billed through Medicare and their Medicaid plan.

Bottom Line: Know the Rules and Use Them to Your Advantage

The Medicare limiting fee may sound restrictive—but for chiropractors, it’s often more flexible than it appears. By understanding when it applies (and when it doesn’t), your office can stay compliant, avoid undercharging, and maintain a strong cash flow.

Need help navigating these billing nuances? Schedule a FREE Discovery Assessment today to find out if we can help you keep your practice protected.