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E&M Coding BASICS for Chiropractors



What is E&M?

E&M simply stands for Evaluation and Management. To most Chiropractors, these are better known as “Exam” codes. The Evaluation & Management codes that are most common in a chiropractic office are 99201-99205 (New Patients) and 99211-99215 (Established Patients).


New or Established? It may not be what you think.

The first step in E&M coding is to decide whether your patient is considered a NEW or ESTABLISHED patient. While this may seem like a no-brainer, it may not always be what you think. It can be pretty easy to confuse NEW CASE and NEW PATIENT with patients you have not seen in a long time.


By Definition:

  • A NEW PATIENT is one who HAS NOT received professional services in your office within the last 3 years.

  • AN ESTABLISHED PATIENT is one who HAS received professional services in your office within the last 3 years.

Different scenarios to consider:

1) Patient returns to your office after 4 years with the same chronic issues. - Because this patient has not been seen in your office for longer than THREE years this would be considered a NEW PATIENT exam.


2) Patient returns to your office after 18 months with a new injury due to a recent car accident. - This may be the start of a new case; however, coding should reflect that this is an ESTABLISHED PATIENT exam (99211-99215).


3) Patient returns to your office after 2 years. When they came in previously, they were seeing a different doctor in your office. - Because this patient has been seen IN YOUR OFFICE within the last THREE years, this must still be coded an ESTABLISHED PATIENT exam (99211-99215).


Modifier 25

Modifier 25 represents a significant, separately identifiable Evaluation and Management Service by the same physician on the same day of the procedure or other service.


For Chiropractors, Modifier 25 is typically used when an Exam is performed on the same day as an adjustment.


Most payers will pay for the Exam AND the adjustment when you append Modifier 25 to your exam code (99201-99205/99211-99215)


Some Tips:

  • Modifier 25 should only be used when the exam is a separately identifiable evaluation service.

  • Things like routine palpation and ROM checks are a component of your adjustment code (98940-98942) and do not warrant a “separately identifiable evaluation service”.

  • Document your exam clearly and apart from your adjustment.

  • Bill for what you do. If your documentation only supports a 99202, that’s the code you should use.

Level of Exam

E&M codes have many rules and components that can make selecting the most appropriate code a bit complex.

  • There are several components for each level of E&M.

  • The requirements differ from new to established patients.

  • Code selection is based largely on the following THREE KEY COMPONENTS; Patient History, Examination, and Clinical Decision Making

Note:

  • With a NEW patient, you must meet or exceed the requirements for ALL THREE of the key components.

  • With an ESTABLISHED patient, you must meet only TWO of the THREE key components.

Some Tips:

  • Chiropractors should rarely, if ever, bill 99211 – This is an established patient code that does not require the presence of a physician or other qualified healthcare professional.

  • Chiropractors should rarely, if ever, bill 99204 or 99215. – Chiropractic offices do not typically see patients that present with problems that would justify the high level of clinical decision making required to support the use of these codes.

  • If a Review of Systems is not documented, the highest level of exam you can bill is 99201 for a NEW patient and 99212 for an ESTABLISHED patient.

  • If PFSH (past, family, and social history) is not documented, the highest level exam you can bill is a 99202 for a NEW patient and 99213 for an ESTABLISHED patient.

  • Under-coding in hopes that you can simply fly under the radar could easily backfire. When you bill a 99202, you’re indicating that the presenting problem isn’t very severe and should be resolved quickly. Again, bill for what you do!


To Learn More


Download our QUICK REFERENCE CHART for your office.


For an in-depth look, here’s our full E&M Coding Guide.



Getting It Documented

Are we all familiar with the old saying…” if it isn’t documented, it didn’t happen”?


Well, that doesn’t ever have to be you.


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


If you need a time-tested, comprehensive, and complete documentation system in your office we can help!


Document Plus can be fully integrated with your existing computer and practice management software and customization to fit your practice is built right into the system.


Please call to schedule your free software demo. 800-642-0600



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