Tips for Chiropractic Evaluation and Management Coding

Tips for Chiropractic Evaluation and Management Coding

Follow the rules when mapping out a compliant plan of care.

Chiropractic physicians use evaluation and management (E/M) codes to describe the work involved in determining what is wrong with a patient and creating a plan of care. After a plan of care is in place, the work is carried out at subsequent encounters.

Map Out the Journey of Chiropractic Care

Chiropractic care can be compared to a journey. It has:

  • An origin or starting point (the initial evaluation or E/M visit);
  • A road map that outlines the path (treatment visits, often reported with Chiropractic Manipulative Treatment (CMT) codes); and
  • A destination (the discharge evaluation or E/M visit).

An episode of chiropractic care without an initial E/M is like a journey without information indicating where it began; and an episode without a discharge E/M encounter is like a journey without a destination.

Depending on the duration of the care plan, there may be a few update evaluations (i.e., lane changes or turns along the journey). If those updates are significant and separately identifiable from the established plan of care, billing a subsequent E/M code may be warranted.

Follow E/M Rules

E/M codes have many rules and components that can be difficult to understand. Solo providers who prefer to focus on their patients’ clinical needs, rather than become coding and documentation experts, may not take the time to learn the codes and guidelines.

Here are a few quick tips that can be helpful to chiropractors and other solo practitioners who lack coding support.

Chiropractors should rarely, if ever, bill high-level codes such as 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making 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 these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. This is primarily because they do not see patients with a high enough type of medical decision-making based on the risk of morbidity and/or mortality. These patients rarely have presenting problems to justify high level E/M encounters.

If a review of systems is not documented, 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 (or for established patients, 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making).

If past, family, and social history is not documented, 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 these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity).

Chiropractors should rarely, if ever, 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. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services (aka, the nurse’s code) because the work is almost always included in other codes. If there is a true evaluation, then it will likely meet the criteria for 99212 because it’s fairly straightforward.

Billing low-level E/M codes to stay under the radar, such as 99202, without understanding the coding rules, implies the nature of the presenting problem must not be very severe. These low-level exams are not part of a lengthy episode of care.

If there is a written request for an evaluation from an appropriate source, and the patient is sent back to the source with a written report, a higher value consultation E/M code may be appropriate.

These tips address a few of the top issues for E/M coding. These tips are not a substitute for a true understanding of E/M coding. Providers are encouraged to seek out training to become proficient in coding or hire coding professionals.

Evaluation and Management – CEMC


Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, QCC, MCS-P, CMHP, AAPC Fellow, is principal of Gwilliam Consulting LLC, and Clinical Director for Advanced Provider Solutions EHR software and PayDC Chiropractic Software. He graduated from Palmer College of Chiropractic as Valedictorian. With a Bachelor degree in Accounting and a Master’s of Business Administration, Gwilliam provides expert witness testimony, medical record audits, consulting, and online courses for healthcare providers. He speaks publicly and has written and contributed to reference books and articles for publications. Gwilliam is a member of the Provo, Utah, local chapter.

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