Coding-documentation synergy: The key to claims payment

By establishing a solid foundation for your coding practices, you will increase your reimbursement and simplify your appeals.

No coding and reimbursement conversation is complete without a discussion about documentation. Without documentation that supports your coding practice, you may as well throw money to the wind. In February of 2018, the Office of Inspector General published a report, “Medicare needs better controls to prevent fraud, waste and abuse related to chiropractic services.” In this portfolio report, the improper payment rate for chiropractic services ranged from 44% to 54% because the CERT program “identified that improper payments were made for services that were medically unnecessary, billed with an incorrect procedure code, not documented or insufficiently documented.” What this means for us as an industry is that someone else can come and recoup your money.

Components of documentation

We’re going to simplify the documentation requirements to cover some 95% of everything you do. Accurate documentation begins at the point of care and may require any combination of the following five essential elements:

Time
Anatomic region
Technique
Treatment purpose
Provider involvement

In the scope of this article, we can’t cover every CPT code, but we will equip you with the skills to identify exactly what each code requires in your notes. Take therapeutic exercise (CPT 97110) as our example. A quick Google search for CPT 97110 gives us the American Medical Association (AMA) definition, “Therapy procedure using exercise to develop strength, endurance, range of motion and flexibility, each 15 minutes,” which immediately tells you three things: it’s timed, it involves exercises and it serves specific functional goals. From that single line, you know you must:

Document the total face-to-face minutes (time component).
Describe which exercises you performed (technique component).
Explain why those exercises were chosen (treatment purpose).

Putting it into practice can be as simple as “Dr. Smith spent 11 minutes working with the patient on proper squat techniques to strengthen her quads and help her return to her pre-injury status.” In one sentence, we hit all three components and even added a fourth point for an anatomic region. With one sentence, you are now going to get paid or win any appeal from a payer that covers this code.

By reading any CPT definition, extracting its key elements and mapping them directly into your chart note, you’ll ensure every code you submit is fully supported and payable.

Boosting revenue

Getting claims paid on the first submission is the most efficient way to improve your practice’s cash flow. Too frequently I hear “submission is the easy part; it is following up with accounts receivable that’s hard,” but it is the poor coding and documentation review during submission that is creating a mountain of work in accounts receivable.

Sometimes providers think their documentation won’t matter because they see mostly commercial and Medicare cases, but there has been a notable uptick in commercial insurance chart audits in 2025; more than in the previous five years. With audit activity on the rise, you must ensure your claims are clean, compliant and fully payable on first submission.

For those readers who are heavily involved in motor vehicle accident (MVA) and workers’ compensation (WC) cases, remember adjusters are trained to find every possible reason to deny payment. Don’t make your practice the easy target.

Appeals

Even the best-prepared claim may face denial; you just want to be indisputably correct when you appeal the denial. A robust appeal hinges on a clear narrative that maps documented elements to CPT requirements. If you followed our instructions for documentation, draft a succinct explanation highlighting where each note satisfies code criteria (e.g., 20 minutes of provider-attended electrical stimulation for CPT 97032). Your appeal letter should identify the patient, date of service, CPT code and denial reason, summarize the documented elements with chart citations, explain medical necessity and formally request reconsideration. Track submissions and outcomes in a centralized dashboard to refine your documentation and appeal strategies over time.

Compliance beyond getting paid

In February 2025, a DC in Eureka, Illinois, was convicted of defrauding Medicare and other insurers out of more than $1.5 million by billing for services she did not perform and misrepresenting modalities delivered. This conviction underscores that every entry in your chart must correspond exactly to what occurred: The provider listed must be the one who actually rendered the service, and the treatment details (duration, technique, device settings) must reflect reality. Any overstatement or fabrication not only risks claim denials and audits but can also lead to severe civil or criminal penalties.

This DC faces up to 10 years in prison for healthcare fraud, up to 20 years for each count of wire fraud, fines of up to $250,000 per count and up to three years of supervised release on each conviction. This case illustrates the devastating legal and financial consequences you risk if your documentation does not mirror the exact physical events that took place in your practice.

Final thoughts

Securing revenue, both on first submission and through appeals, starts with documentation that fully aligns with CPT requirements. When every note accurately captures these requirements, your practice will experience fewer denials, faster reimbursement and stronger appeal outcomes. As audits increase, delegating your coding and appeals to seasoned professionals can give you peace of mind as well as more valuable time for patient care.

Konstantin Chernukhin is the CEO of American Chiropractic Billing, with experience in both medical billing and personal injury practice management. He specializes in chiropractic reimbursement and revenue cycle optimization. For more information, email info@chiropracticbilling.com.