Every experienced chiropractic billing company knows that Evaluation & Management (E/M) codes are among the most important code sets used in chiropractic offices. Knowing the CPT guidelines for billing E/M services and payer rules is crucial to ensure maximum reimbursement, avoid penalties for incorrect reporting, and improve overall chiropractic billing efficiency.

Essentials of Chiropractic E/M Documentation and Coding

The American Chiropractic Association (ACA) recommends that all chiropractors use the E/M documentation requirements developed by the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS).

  • Proper documentation of E/M services: To choose the correct code to report the E/M service, all patient information must be properly documented in accordance with the AMA’s CPT rules. The three key components of E/M documentation are:
    • Patient history: The chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family and/or social history (PFSH) are the four components of patient history as required by the E/M documentation guidelines.
    • Examination: The basic requirements of the chiropractic E/M exam as per CMS include a visual assessment of range of motion noting pain, manual muscle tests, deep tendon reflexes, dermatomal sensation, orthopedic tests and palpation findings.
    • Medical Decision Making (MDM): The number of diagnoses or treatment options, risk of complications and/or morbidity or mortality, and amount and/or complexity of data to be reviewed will determine the type of decision making: Straight Forward, Low Complex, Moderate Complex, or High Complex.
    • New vs. Established Patient: The code set for new patients is CPT 99201-99205 and the code set for established patients is CPT 99211-99215. A new patient is one who has not received any professional services from the chiropractor or another qualified chiropractic physician who belongs to the same group practice, within the past three years. The determination is based on the date the office last saw the patient (www.chiroeco.com). All patients who do not fall in this category are established patients.
  • Coding E/M services: As AAPC explains, E/M codes (99201-99205, 99211-99215) are used by chiropractic physicians to describe the work involved in determining what is wrong with a patient and creating a plan of care. Once a plan of care is created, actual treatment is provided at additional encounters.The E/M codes reported should correctly represent the level of history, examination, and clinical decision making required. Therefore, the chiropractor must select the appropriate code level within the E/M code set to reflect the level of service provided to the patient. This will indicate how they should be reimbursed for that care. When billing for an E/M service:
    • All CPT guidelines must be met for each service
    • The service must be separate and distinct from any other service performed on the patient that day

Tips for Accurate E/M Coding

  • Avoid billing high-level codes – Chiropractors normally do not see patients with problems that have high risks of morbidity or mortality. Therefore, it is not appropriate for chiropractors to bill high-level codes such as 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires the 3 key components: a comprehensive history; a comprehensive examination; MDM of moderate complexity, and 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of the 3 key components.
  • Without documentation of a review of systems, AAPC says the highest E/M code that can be reported is 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making. For established patients, the highest E/M code that can be reported is 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of the 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making).
  • In absence of past, family, and social history documentation, the highest E/M code that can be reported is 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making(or for established patients, 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of the 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity).
  • Do not (or rarely) bill 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. 99211 is a low complexity examination for an established patient. The CPT book states that this code “may not require the presence of a physician”. This is a nurse’s code and the work is typically bundled into other codes
  • A higher value consultation E/M code may be appropriate if the patient is sent back with a written request for an evaluation from an appropriate source (www.aapc.com).

The medical record documentation should support the level of service reported to a payer. Medical necessity is the main criteria for coverage. Medical billing companies providing chiropractic billing services have a good understanding of E/M coding and billing for this specialty. They can help providers review documentation, choose the right codes, and submit error-free claims. However, it is the physician’s responsibility to ensure proper documentation to support E/M work.