CMT plus E/M
This question, like all others, depends on who you are billing.
Who is the carrier. As this is an apparent personal injury (auto) claim, what code utilization standards are incorporated into the reimbursement component of the state auto statute?
Assuming general coding priniciples, I note that an MD performed the service. Are you sure of that? While not inappropriate for an MD to report CMT, or a DC to report OMT (the difference is in outcome not the licensure of the provider as the code title suggests), in my experience, I see MDs billing CMT where the practice is a multi-specialty practice (MDs and DCs and sometimes PTs who join together to form a multi-disciplinary group). If this is the case as I suspect, the billing suggests that a DC actually performed the service and the MD is billing it under incident to rules. You must evaluate if the state licensure rules, as well as the rules pertaining to the reimbursement scheme (looks like an auto case - so the state auto statute) permit incident-to billing.
With Respect to the E/M: Assuming that this was an initial encounter, I would likely agree that the E/M service is beyond the usual pre, intra and post service analysis contained in the CMT service. As such, reporting the -25 on the E/M service would be appropriate. If this was an established patient encounter, then I would need to compare the prior notes to see what was substantively difference to justify the repeat analysis.
I score the E/M service as follows: H=EPF, E=EPF (95) PF (97), and DM=Low. If a new patient, 99202, if an established, 99213.
With Respect to the CMT: I note that the manipulation service was performed on regions of the spine that are not clearly related to the injury. The subjective data suggests primarily neck complaints and some vague mid back/low back discomfort. The diagnosis suggests sprain/strain of the neck, mid back and low back although the examination data does not confirm this. At best it shows myofascitis that may or may not have been caused by the accident. With CMT, especially where a DC is involved, it is common to stretch the areas involved to support the higher 98941 code. This is a form of upcoding and before approving a 98941 in this case, I would like to see the patient intake data that contains the patient's actual complaint. My guess is that it is limited to the cervical region. Once that was evaluated, you would be able to make a definitive determination on the level of CMT.
Note: The use of the -59 modifier on the CMT code is neither required nor proper as suggested by one commenter.
Finally, there is insufficient information to determine what "stretching exercises" means. Were these recommended or performed? Even if performed in the office, it looks like it will be a "couple of weeks" until the patient returns. As such, there could be no expectation that the in-office exercises would yield a substantive functional improvement in the patient's condition and as such, they would not be medically necessary.
Also, I am concerned with the approach that some commenters suggest. There seems to be a "try this" theme to some of the responses. As coders, we are required to apply appropriate criteria to make a correct representation of the service so that the carrier can make a correct payment determination. Accuracy is our goal. Consider that the correct representation of the service might cause the service to be correctly denied such that the payment burden shifts to the patient.
As I spend most of my time defending providers who have tried any number of seemingly good ideas to get paid - only to face substantial post payment refund demands or worse - civil/criminal false claims litigation, all should be extremely careful in suggesting or following such approaches.
Research the applicable standards to the carrier you are billing. Find out what code usage rules apply. Only then can you determine the correct answer to your question.
I hope you find this useful.
Michael D. Miscoe JD, CPC, CHCC
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA
President-Elect, AAPC National Advisory Board
Member, AAPC Legal Advisory Board
Chair, AAPC Ethics Committee
AAPC Certified ICD-10 Trainer