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M111 Remark Code: Manipulation Denied, X-Ray Refused

M111 means the payer does not pay for chiropractic manipulative treatment when the patient refused to have an x-ray taken. The payer relies on the x-ray or other evidence to support the subluxation being treated.

Quick facts

Code
M111 (RARC M111)
Status
Active In use since January 1, 1997.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • CO (Contractual Obligation): The manipulation is denied, and the chiropractor absorbs it unless the patient agreed in advance to pay.
  • PR (Patient Responsibility): The patient is responsible when an appropriate advance notice or financial agreement was obtained.
Official description
We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What M111 means

Chiropractic manipulative treatment is covered by Medicare and many other payers only to correct a subluxation of the spine. The payer needs evidence of that subluxation. An x-ray is one way to show it. M111 tells you that the patient declined an x-ray and, as a result, the payer would not pay for the manipulation.

Payer rules differ on whether physical examination findings can substitute for imaging. Medicare, for example, accepts physical examination documentation in many cases, so M111 is more likely to reflect a specific payer or program rule than a universal one.

Common causes

  • The patient declined imaging and the chart did not otherwise establish the subluxation in a way the payer accepts.
  • The claim or records referenced the refusal, prompting the denial.
  • The payer’s policy requires imaging for the diagnosis or level billed.

How to fix it

  1. Check the payer’s policy on how subluxation must be demonstrated.
  2. If examination findings are acceptable, make sure the records document them in the required format and appeal with those records.
  3. If imaging is required, discuss with the patient whether they will consent. A new x-ray may support future visits, not always past ones.
  4. If the denial stands, bill the patient only where an advance notice or plan provision allows.

How to prevent it

  • Explain to new patients why imaging or examination evidence is needed for coverage.
  • Document subluxation findings thoroughly at the initial visit.
  • Obtain advance notices when coverage is uncertain.
  • Review medical necessity and prior authorization prevention for building coverage checks into intake.

Codes that may appear with M111

  • CO-50 (These are non-covered services because this is not deemed a 'medical necessity' by the payer.): The manipulation was not considered medically necessary without supporting evidence.
  • CO-96 (Non-covered charge(s).): Non-covered charge, with M111 giving the x-ray refusal as the reason.
  • M1 (X-ray not taken within the past 12 months or near enough to the start of treatment.): The x-ray was not taken within the required time frame.
  • M122 (Missing/incomplete/invalid level of subluxation.): The level of subluxation was missing or invalid.
  • MA121 (Missing/incomplete/invalid x-ray date.): The x-ray date was missing or invalid.

M111 FAQ

Does Medicare always require an x-ray for chiropractic care?

No. Medicare allows subluxation to be demonstrated by x-ray or by physical examination findings. M111 applies when the payer's decision relied on a patient's refusal of an x-ray.

Can I bill the patient?

Only if you gave any required advance notice and the patient agreed to pay, or if the plan assigns the amount to the patient.

Should I document the refusal?

Yes. Record the refusal and the reason, along with your physical examination findings, in case the payer's policy permits coverage on that basis.