One that you can say about billing, coding & documentation for your chiropractic services is that it is constantly changing.  This certainly may cause frustration to many DC’s who believe they are doing things right only to find out that their claims are suddenly rejected, additional paperwork is requested or – in the worst case scenario – a post-payment audit demands money back.

I’m not much of a conspiracy theory guy but it does indeed look, at times, as if the insurance payers are constantly changing the rules to cause us to stumble. Fortunately, I am sick and twisted enough to enjoy watching  THEM and reporting new changes and challenges to YOU.

Here’s the latest in the way of insurance shenanigans that is making its way across our country in the form of your E/M codes.

What’s an E/M Code?

First, let’s define E/M.  It simply stands for Evaluation & Management.  To most chiropractors, these are “exam” codes.  While that is one use of the code (that’s the “E” portion), it is not the exclusive use of these codes.  Most of these codes that are used on a daily basis in chiropractic offices reside in the CPT codes from 99201-99205 (for New Patients) and 99211-99215 (for Established Patients).

New Patient Confusion

The next question that often pops up when considering E/M codes is:  when is a new patient a new patient?  According to the CPT (remember: they make the rules, not me!) a new patient is defined as follows:

If a patient has not received any professional services by the physician or physician group practice (same physician specialty) within the last three years, then they are considered a New Patient.

Understanding that rule is critical to coding your patient encounters correctly, making sure you don’t leave money on the table and avoiding post-payment demands.

Since I get many emails from well-meaning, law-abiding chiropractors who have confused this issue, let me go over a few example scenarios and the proper coding for them:

a)    Patient is in a MVA.  The patient has not been in your office for over a year, but they get into a new injury (ex: car accident).  You perform an exam.  For coding purposes, they are still considered an Established Patient (99211-99215).  Certainly, I understand that their symptoms may be new or that this may bring up questions about pre-existing conditions, but the rule is the same!

b)    Patient has not seen you before.  The patient has not been in the office for two years.  When they previously came, they saw a different DC in your practice.  You perform an exam.  This patient’s encounter should be coded as an Established Patient exam (99211-99215).  Even though you personally have never seen this patient, another physician in your group has and since you are in the same specialty (chiropractic), you must code this as an Established Patient.

c)     Long term patient.  Your very first patient comes back in after 5 years (apparently, you fixed him up good!).  He’s got the same problems as he did 5 years ago.  You take xrays and his spine looks the same. You perform an exam and it feels like you stepped into a time machine – same results as 5 years ago.  What do you code?  New patient!  Doesn’t matter the scenario, this patient has been out of your office and received no treatment in 5 years so even though his problems are old, in terms of billing and coding, he is a New Patient (99201-05)

Modifier 25 Mayhem

The next big problem that occurs for many chiropractors is the fact that they often perform an exam and they adjust the patient on the same encounter.

While some payers may have specific rules about this, most payers will pay for BOTH services as long as you use Modifier 25 with your E/M code (ex: coding 99212-25 for your exam and 98940 for your adjustment).

In theory, this should be the end of the story.  But I didn’t just step off the boat yesterday and I have seen a zillion denials of this service – even with the Modifier-25 in place.

If you’ve been frustrated by the fact that you can’t seem to get paid for BOTH your exam and your adjustment on the same day, here are a few suggestions for how to remedy this situation:

1)    Make the Exam Extremely Obvious! (for those using EMR)  I can tell you from my training as an Auditor, that any human looking at your claims does so very, very quickly.  Auditing is a volume-based business; the quicker they can deny your services, the more money they make.  At times, this causes them to “miss” your Exams – unless you make it really obvious that you have performed an exam.  In their defense, our routine daily objective findings (ex:  ROM, palpation, muscle strength tests, etc) as chiropractors do look similar to our exam findings.  So, unless you make it extremely obvious, auditors may not notice you performed an exam.  My suggestion is extremely simple but it works!  Make the first sentence of your chart notes something that states that you performed an exam!  For example:

1. a.     “An examination was performed today on…” or

1. b.     “Today, Mr X reported for a re-examination to evaluate his progress…

1. c.      “Mrs Z consulted our office today  as a New Patient for complaints of…”

2)    Use a Separate Exam Form (if you’re still using paper notes).  Similarly, if you are still using paper notes, have a separate Exam Form that you use for that purpose.  It’s too easy for an auditor to miss the fact that you performed an exam when it’s buried in your daily SOAP notes.  Make it glaringly obvious – have the form read “EXAM FORM” or “RE-EXAMINATION FORM” or even “PROGRESS EXAMINATION FORM.” Anything that will make it apparent to even the most distracted auditor.

3)    Know the Purpose and Definition of Modifier 25.   Sometimes, it’s not apparent that the doctor needed to perform an examination or that the E/M code did not represent a separately identifiable evaluation service other than the routine pre- and post-service components of your adjustment.  For example, the fact that you palpate your patient or perform ROM checks does NOT warrant billing an exam code.  It’s a component of your adjustment code (98940-98942).  Similarly, while a different diagnosis, symptom or problem may warrant the examination, according to the CPT:

“The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.  As such, different diagnoses are not required for the reporting of the E/M service on the same dates.”   

In other words, it’s not required (and will not be enough) to simply change the diagnosis codes and bill an E/M encounter.  The key factor is that something DIFFERENT must be going on that warrants you billing the E/M in addition to your adjustment.

4)    Be Prepared to Appeal ANYWAY!  Some of you may be saying to yourself “we already do that!”  First, congratulations.  Second, I’m sorry you got a denial anyway.  Third, keep the insurance payers honest and have an appeal letter ready to launch.  This problem is not unique to chiropractors.  Just about every billing/coding publication I read has articles dedicated to fighting E/M denials.  Some payers automatically deny any claim with Modifier 25 attached because they presume you either won’t fight it or that you’ve done something wrong.  While practice certainly may not be ethical, it’s reality.  Be aggressive and fight back when you know you are right.

Hopefully this clears up some E/M confusion and helps you get paid for the good work that you do!