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Checklist Systems and E&M Coding

Correct use of Evaluation and Management (E/M) codes is essential to proper insurance reimbursement.

How does Document Plus help ensure that your clinical documentation for Evaluation & Management (E&M) is Quick, Easy, and Accurate...every time?


We use Checklist systems!

The checklist systems developed by DocPlus are;

  • Highly accurate record collection tools for providers.

  • Designed to help you better serve patients while meeting the needs of 3rd party payers, Medicare, and Attorneys.

  • Designed to support ICD-10 diagnosis and treatment at higher levels required for ICD-10 coding.

  • Designed to support E&M coding at any level



E/M for Chiropractic

The proper use of Evaluation and Management (E/M) codes is an essential part of proper insurance reimbursement. Claims for appropriate E/M services should be made when the services are rendered, and should be documented in the patient’s records. Unfortunately, coding for E/M services is one of the least understood elements of chiropractic coding.

E/M codes can be used in chiropractic when services are significant and separately identifiable from the routine services done within the basic Chiropractic Manipulative Treatment (CMT) code set (98940-98943). The CMT code set includes routine E/M services.

Note the official CPT statement from the AMA regarding chiropractic use of an E/M code: “Chiropractic Manipulative Treatment (CMT) is a form of manual treatment to influence joint and neuro- physiological function. This treatment may be accomplished using a variety of techniques. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional Evaluation and Management services may be reported separately using the modifier -25, if the patient’s

condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure.”

– CPT 2011

**NOTE: According to the ACA, 99205 E/M codes are rarely used in the chiropractic profession as this E/M code usually deals with a high complexity decision making of life and death consequences. Utilization of this code may alert a “RED Flag” to insurance carriers. Proper documentation is essential!

In general, of the “new patient” codes, 99201 should be used only slightly less frequently than 99205. The goal is not to game the system and upcode, but if you find yourself using 99201 regularly, consider auditing your own billing and documentation practices. You will most likely find that you are either undervaluing your services or under documenting. (Consider the use of a 99211 or 99201 for a physician visit as a red flag indicating potential under coding.)

The checklist systems developed by Document Plus are designed to make documenting for E&M easier no matter the level.



E&M Coding can be complex. There are several documentation components for each level of E&M. The requirements differ from new to established patients and are based on three key components;

  • Patient history

  • Examination

  • MDM (medical decision making)

The following documents will review the guidelines for selecting appropriate E/M codes and the criteria that must be met for each of the three KEY components of Evaluation and Management coding.

The E&M Quick Chart is a quick reference guide. The full E&M Coding Series is a detailed comprehensive guide.


Document Plus Technologies has a time tested, forward thinking documentation solution for your practice. It can be fully integrated with your existing computer and practice management software systems and customization to fit your practice is built right into the system.

Please call with any questions or to schedule your free software demo. 800-642-0600

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