Denials and how to not get discouraged with evaluation and management codes, and how to appeal
THERE IS LITTLE MORE FRUSTRATING TO CHIROPRACTORS AND BILLERS THAN EVALUATION AND MANAGEMENT CODES. While the service is required both clinically and documentation-wise, it is being bundled more and more often by third-party payers. If both the chiropractic manipulative treatment (CMT) and the E/M are performed on the same day, even with the requisite 25 modifier appended to the E/M service, the services are bundled and the E/M is being denied. It’s frustrating when a practice performs services and bills according to the rules, and the carrier denies it anyway. And it’s not fair. What to do?
It’s not fair, but…
Keep in mind that when an E/M service is paid at a lower-allowed fee, bundled or not covered, it’s all related to the carrier’s medical review policy, or other payer policy. As a participating provider, one has ultimately agreed to this, whether overtly or not. Provider contracts, allowed fee schedules and payer policy all contribute to the reimbursement of services. None of these, however, diminish the clinically-required elements of evaluation that must be performed, regardless of who is paying the bill.
It should be noted that even when a payer bundles and denies the E/M service with the CMT, it’s not the end of the story. Current Procedural Terminology (CPT) rules still indicate that when performing a “significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service,” it is likely also payable. In chiropractic, it would usually happen when performing an E/M service on the same day as a CMT. In this instance, the 25 modifier is appended to the E/M service. This indicates that proper E/M documentation is included in the record to prove the medical necessity and separateness of this service.
Medicare and most third-party payers expect that initial visits of episodes of care have particular components of documentation. They include:
- Relevant History of Patient’s Condition with Detailed Description of the Present Condition
- Evaluation of Musculoskeletal/Nervous System Through Physical Examination
- Treatment Plan
- Recommended level of care (duration and frequency of visits)
- Specific treatment goals
- Objective measures to evaluate treatment effectiveness
- Date of Initial Treatment
As you can see, these elements align with the exact components of the E/M services of history, examination and clinical decision-making. These fundamentals of E/M documentation also contribute beautifully to the medical necessity of the entire episode of care. It sets the tone and establishes the baseline for the episode. Therefore, these pieces are vital and should not be skipped due to level of payment or bundling.
E/M and rate of return
Physicians who understand the idiosyncratic process of E/M coding documentation also tend to command a higher rate of return on their cognitive labor than their less E/M-savvy counterparts. In other words, if you know how to document and bill accurately for your services, there is a better chance you will get paid for the work you do.
The E/M section of the CPT Coding book is divided into broad categories such as office visits, hospital visits and consultations. These categories can be found in the 90000 section of the book. Most of the categories are further divided into two or more subcategories for E/M services. For example, there are two subcategories for office visits (new patient and established patient) and two subcategories for hospital visits (initial and subsequent). The subcategories for E/M services are further classified into levels of E/M services — these are identified by specific codes. The classification is important because the nature of the physician’s work varies by type of service provided, place of service and the patient’s status.
Doctors of chiropractic in a typical practice most frequently use the New and Established Patient Office Visit E/M codes. Each evaluation and management code is a five-digit number that always begins with 992. The code sets for new patients range from 99201-99205. The code sets for established patients are 99211-99215. The fourth digit in the number represents whether the patient is a new patient (0) or an established patient (1). The fifth digit represents the work and information obtained or the level of history and examination performed as explained in the E/M Documentation Guidelines. There may be other E/M code sets available to the chiropractic office, but these two sets are the most frequently used.
A new patient is defined as:
- Someone who has never been seen in your office, by you or any another doctor of chiropractic in your practice, or;
- A patient who has been seen before but whose last visit was more than three years prior.
Everyone else is considered an established patient for the purposes of E/M coding and reporting. This includes existing patients who changed insurance, were involved in work or auto-related accidents, or any other similar new condition and have been seen in the past three years.
In chiropractic coding and billing, the E/M codes are usually reserved to describe E/M services above and beyond a typical chiropractic manipulative treatment (CMT). Some specific examples of when it may be appropriate to bill both a CMT and an E/M code on the same date of service are:
- New patient visits;
- Established patients with new conditions, new injuries, aggravation or exacerbation of existing injuries;
- Periodic re-evaluation to assess whether a change in treatment is needed.
E/M services should be supported by appropriate documentation. We recommend using the E/M documentation requirements developed by the AMA and CMS. There are two options: 1995 and 1997 guidelines. The primary difference is in the examination component, and we recommend using the 1997 guidelines, including the musculoskeletal specialty examination.
Because evaluation and management codes encompass both the evaluation and management of your patient, they are a critical component of your documentation. Don’t be afraid to appeal denials of E/M services billed on the same visit as a CMT. If the full scope of work was performed for both, prove that with your documentation and insist on payment. It’s the right thing to do.
KATHY MILLS CHANG,MCS-P, CCPC, CCCA, has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices since 1983. She leads a team of 30 at KMC University and can be contacted at KMCuniversity.com.