It’s a dirty little secret among auditors that E/M codes are easy money to take back from doctors.  Unfortunately, as chiropractors, we are no exception and your exams may possibly be the easiest chiropractic audits to fail.  Of course, failure means repayment, which is obviously unpleasant and painful.

Obviously the news is no secret to insurance companies who love to conduct chiropractic audits (in general) and especially for exam codes because these E/M codes have been historically seen as ripe for fraud and abuse.  This is probably why one of the largest BCBS payers in the US just announced a full-scale audit of doctors in Washington, Oregon, Idaho and Utah.

But here’s some good news — your chiropractic exams can also be the MOST solid part of your documentation and among the easiest things to fix so that you won’t be subject to chiropractic audits (or worse, post-payment demands). That’s what we’ll be discussing today, so keep reading!

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 (and as a result, needed my chiropractic audit help) 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 and if you don’t like the sound of chiropractic audits coming your way – code the established E/M!

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 x-rays 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!  The scenario doesn’t matter. Because this patient has been out of your office and received no treatment in 5 years, even though his problems are old, in terms of billing and coding, he is a New Patient (99201-05).

Modifier 25 Mixups

The next big problem that welcomes chiropractic audits into your office is the fact that chiropractors 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 and chiropractic audits caused by this service combination – 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!  I can tell you from my training as an Auditor, that any human looking at your claims does so very, very quickly.  Chiropractic audits are both a volume-based business and a revenue generator for many payers. 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 exam very obvious. In my chiropractic seminars, I teach several strategies to do this very effectively which we don’t have time to discuss here, but the point is the same: it’s got to be clear that you are doing an exam! 

2)    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.  And doing some different prevents chiropractic audits of your E/M codes that cause paybacks!

3)    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 on the part of insurance payers, it’s reality. (In fact, the BCBS entity that I mentioned previously is doing just that; they are full-scale auditing those who use Modifier-25) Be aggressive and fight back when you know you are right.


It’s absolutely possible to accurately document your Exams with exact precision to know which code should be billed.  Many coding books detail the exam requirements for different level exams in terms of required complexity, history, medical decision-making, etc.  Don’t fudge it, if you only document enough to merit a 99202, then that’s what you bill.

And if you’ve been doing it right, don’t sweat the letter that you receive.  As I mentioned previously, E/M codes are a big target for all payers. Appeal their audit instead!

If you’d like to learn the Audit Template that BCBS (and every major payer) is going to use to audit your exams, along with my simple step-by-step “bullet system” to quickly determine how to code correct (and how to defend yourself), you should consider my upcoming Smarter Chiropractic summer seminar in Seattle where we’ll be discussing this — and a whole lot more.  For those of you who are suffering from the heat, this is the BEST time of the year to visit the Northwest – and the seminar will be well worth your plane trip 🙂  Register today to get your early bird discount!