Chiropractors use evaluation and management (E/M) codes frequently, but not at every encounter, as do many of their medical counterparts.
E/M codes are used to describe the work involved in figuring out what is wrong with a patient and creating a plan to manage them.
Chiropractic care can be compared to a journey. There is an origin, or starting point (initial evaluation, or E/M visit), there is a road map, which outlines the path (the treatment visits, often reported with chiropractic manipulative treatment (CMT) codes), and a destination (the discharge evaluation, or E/M visit.)
Depending upon the duration of the care plan, you might insert a few update evaluations (i.e. lane changes or turns along the journey). If those occasions are significant and separately identifiable from the chiropractic manipulative treatment (which includes some evaluation and management), an E/M code could be billed in addition.
Note that an episode of chiropractic care without an initial E/M is like a journey with no information about where it began. An episode without a discharge E/M encounter is like a journey without a destination.
Understanding E/M codes
E/M codes have all kinds of rules and components that solo providers may not take the time to learn. They can be difficult to understand, especially if providers want to spend more time with patients rather than becoming experts with coding and documentation. Here are a few quick tips that can be helpful to chiropractors and other solo practitioners who lack coding support.
There is, of course, much more to evaluation and management coding, but these are a few of the top issues.
- Chiropractors should rarely, if ever, bill for high level codes such as 99204, and 99215. This is primarily because they do not see patients with a high enough type of medical decision making based on the risk of morbidity and/or mortality.
- If a review of systems is not documented, the highest evaluation and management code that can be reported is 99201 (or 99212 for established patients).
- If past, family, and social history is not documented, the highest E/M code that can be reported is 99202 (or 99213 for established patients).
- Chiropractors should rarely, if ever, bill 99211 (aka the nurses code) because the work is almost always included in other codes. If there is a true evaluation, then it will likely meet the criteria for 99212 because it is fairly straightforward.
- Billing low level E/M codes to stay “under the radar”, such as 99202, without understanding the coding rules, implies that the nature of the presenting problem must be not be very severe. Therefore, these low-level exams would not be expected to be part of a lengthy episode of care.
- If there is a written request for an evaluation from an appropriate source, and the patient is sent back to the source with a written report, the higher value consultation E/M codes may be appropriate.
These tips are not substitute for a true understanding of evaluation and management coding. Providers are encouraged to seek out training to become proficient and ensure proper reimbursement.
Evan Gwilliam, DC, MBA, Executive Vice President of ChiroCode Inc. and Find-A-Code LLC, graduated from Palmer College of Chiropractic as Valedictorian and is a Certified Professional Coding and ICD-10 instructor, medical compliance specialist, and certified professional medical auditor, among other things. He provides expert witness testimony, medical record audits, consulting and online courses for healthcare providers. He also writes books and articles for trade journals and is a sought-after seminar speaker. He has a bachelor’s degree in accounting, a master’s of business administration, and is one of the few clinicians who is a Certified MIPS/MACRA Healthcare Professional.