Evaluation and management code selection should be based on time or medical decision making (MDM). MDM is a bit more involved than time, but can be quantified and supported with clear documentation, making it a very defensible option.
E/M code selection based on Medical Decision Making (MDM)
While MDM may be a bit more complex, a framework is provided to guide a practitioner to the correct code. There are three elements of MDM:
- The number and complexity of problems that are addressed during the encounter.
- The amount and/or complexity of data to be reviewed and analyzed.
- The risk of complications and/or morbidity or mortality of patient management.
- Problems (what kinds of problems does the patient present with and how many of them are being handled by the provider?)
- Data (how much history from others, information from diagnostic tests, or records from other providers must be ordered or reviewed?)
- Risk (how risky is the treatment or diagnostic tests that this patient needs?)
Level 2
This first table is for a level 2 E/M service.
| Level of MDM | Problems | Data | Risk |
| Straightforward | Minimal 1 self-limited or minor problem | Minimal or none | Minimal risk of morbidity from additional diagnostic testing or treatment |
In order to qualify for a straightforward level of MDM, which is required for a level 2 E/M service (99202 for new, or 99212 for established), the problems should be minimal, the data may be minimal or none, and the risk should also be minimal. To use MDM, two of the three elements must be met, and time is not a factor.
Sample verbiage to support a level 2 (99202/99212) E/M that includes Problems and Risk might be:
“The Medical Decision Making at this encounter is straightforward. The problem appears to be self-limited or minor because it is transient and not likely to permanently alter the patient’s health status. There appears to be a minimal risk of morbidity or functional impairment of substantial duration.”
The definition of “self-limited or minor” for this statement was taken straight from the official guidelines, as was the definition of “morbidity”. This documentation is not required, but it would make a reviewer’s job much easier if they see this kind of statement and can line it up with the E/M Guidelines for a “straightforward” level of MDM.
Level 3
The table is a bit more complicated for level 3 (99203/99213) exams. This is an abbreviated version (please see the official table for the full details):
| Level of MDM | Problems | Data | Risk |
| Low | Low -2 or more self-limited or minor problems -1 stable, chronic illness -1 acute, uncomplicated illness or injury -1 stable, acute illness -1 acute, uncomplicated illness or injury requiring hospital | Limited -Order or review two tests or notes OR -Independent historian | Low risk of morbidity from additional diagnostic testing or treatment |
The definitions for each of these items, and much more detail for the “Data” column can be found in the official guidance, as mentioned above.
Sample verbiage to support a level 3 (99203 or 99213) E/M that includes Problems and Risk might be:
“The Medical Decision Making at this encounter is low. The problem appears to be acute and uncomplicated because it is recent, likely short-term, and full recovery without functional impairment is expected. There appears to be a low risk of morbidity or functional impairment of substantial duration.”
This example supports a “low” level of MDM, which is required for a 99203 or 99213. The definition for an “acute and uncomplicated problem”, which is one of the five choices from the “Problems” column is taken from the guidelines, as is the definition of “morbidity” again.
Level 4
A level 4 exam would be much rarer in a chiropractic setting, as can be seen from the table below.
| Level of MDM | Problems | Data | Risk |
| Moderate | Moderate -1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; -2 or more stable, chronic illnesses; -1 undiagnosed new problem with uncertain prognosis; -1 acute illness with systemic symptoms; -1 acute, complicated injury | Moderate -Order or review three tests or notes or ind. historian -Independent interpretation of test -Discussion with external provider | Moderate risk of morbidity from additional diagnostic testing or treatment |
The full definitions of the problems listed here can be found in the official guidelines, but most of them are the kinds of things that do not present for care in a chiropractic office. The data analysis required for a level 4 is far more extensive than what is necessary in the majority of typical musculoskeletal complaints, and the examples of things that are considered “moderate” for the risk are as follows:
- Prescription drug management
- Decision regarding minor surgery with identified patient or procedure risk factors
- Decision regarding elective major surgery without identified patient or procedure risk factors
- Diagnosis or treatment significantly limited by social determinants of health
Managing prescriptions and surgeries are outside the scope of practice for most chiropractors, and social determinants of health, such as homelessness, may impact typical chiropractic care, but it would likely be the exception, not the rule.
Sample verbiage to support a level 4 (99204 or 99214) E/M that includes Problems and Risk might be:
“The Medical Decision Making at this encounter is moderate. The problem appears to be acute and complicated because there are multiple treatment options and requires evaluation of other body systems. There appears to be a moderate risk of morbidity or functional impairment of substantial duration.”
The problem chosen here uses verbiage from the definition found in the official guidelines. The intention would be to make these terms to be very recognizable by someone familiar with the rules. As a reminder, none of this documentation is specifically required, but it is offered here as a suggestion, to create a defensible record, should it be challenged.
In conclusion, understanding and effectively utilizing Evaluation and Management (E/M) codes is essential for chiropractic physicians to ensure proper documentation, compliance, and reimbursement. With updates that have simplified the guidelines, chiropractors have the opportunity to focus on patient care while maintaining defensible records. By grasping the differences between new and established patients, leveraging time or medical decision making (MDM) for code selection, and adhering to medically appropriate standards, providers can navigate the complexities of E/M coding with confidence. See parts 1, 2, and 3 of this blog post for more information. Ultimately, accuracy in coding not only supports better clinical outcomes but also protects the practice from unnecessary scrutiny.
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.