Evaluation and Management (E/M) procedure codes are the most widely used CPT codes in all of healthcare in the United States. There are several categories of codes for different circumstances, from hospital care, to nursing facilities, telemedicine, and even home-based evaluations. However, the most common in a chiropractic setting, would be the codes categorized as “Office or Other Outpatient Services” (99202-99215). Understanding the rules around E/M codes is key to ensuring effective and defensible documentation, and proper payment. This is part 1 in a 4 part series about the relevant rules for coding and documenting for evaluation and management services in a chiropractic setting.
New Versus Established
There are two subcategories for office visits: new patient and established patient. As defined by the CPT code guidelines, a new patient is “one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” This means that even if the patient sees two different chiropractors in the same clinic, they are not a new patient. But, if there are providers in an multidisciplinary clinic, in different specialties, then the patient would be considered new to each of them, even if the exams were performed on the same day.
An established patient is “one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” If a patient was last seen two years, eleven months, and three weeks ago, they are still considered “established” for the purpose of code selection.
While established patient office codes would be appropriate to report re-exams during an active course of care, they would also be used as the initial exam for a new episode, unless more than three years have passed. In other words, a new episode of care does not change the patient’s status to “new” for the purposes of code selection. The same is true if the patient is suddenly in a car accident or obtains new health insurance. That has no bearing on whether the service is considered “new” or “established” when choosing the CPT code.
Updates from 2021
There was a massive overhaul to the Evaluation and Management (E/M) coding guidelines in 2021, with a few updates in 2023 and 2024. The AMA explained the purpose of the changes as follows:
“…documentation for E/M office visits will now be centered around how physicians think and take care of patients and not on mandatory standards that encouraged copy/paste and checking boxes.”
In other words, the AMA saw that note bloat was becoming a real problem and the changes were designed to simplify the process and allow providers to focus more on patients.
Regardless of all the guidelines and details, the underlying determining factor has been, and will always be, medical necessity. It would not be appropriate to bill a level 4 exam (99204) just because the notes appear to list the right elements from the guidelines, if the patient’s issue was straightforward (i.e. 99202). A lengthy exam with a diagnosis of cervicalgia doesn’t make sense. It is only a symptom and is not a true condition and very little work would be expected to come to such a conclusion. But a lengthy exam for a patient with a very complicated history and multiple complaints and chronic issues on top of acute ones might satisfy the medical necessity requirement.
The biggest change in 2021 was the elimination of History and Examination as factors for determining the overall E/M level of service. Code selection instead became based on medical decision making (MDM) or the total time spent performing the service on the day of the encounter. The details around how these are calculated were clarified and updated in the 2021 change. Find out more about each of these concepts in parts 2, 3 and 4 of this series on Evaluation and Management coding and documentation for chiropractic.
Dr. Gwilliam is the Senior Vice President of Practisync, which helps practices improve efficiency and collect more through outsourced expert billing services. You can reach out to Dr. Gwilliam at evan.gwilliam@practisync.com.