One of the most common areas for increased scrutiny by Medicare and private insurance are the E/M codes. Most doctors don’t understand them, causing mistakes.
DCs believe they are doing things right only to find out that their claims are suddenly rejected, additional paperwork is requested, or a post-payment audit is requesting money back.
E/M simply stands for Evaluation & Management. To doctors, this means “exam” codes. The specific codes that are used daily in chiropractic offices are CPT codes 99201 through 99205 (for New Patients) and 99211 through 99215 (for Established Patients).
The New Patient Confusion:
I’m often asked, when is a new patient a new patient? According to the CPT, a new patient is defined as:
“A patient that has not received any professional services by the physician or in a physician group practice within the last three years, is considered a New Patient.” In multi disciplinary practices the rule applies to physicians of the same physician specialty.
Understanding this rule is critical to coding your patient encounters correctly and avoiding pre or post-payment audits.
I commonly see this when an existing patient comes in after an auto accident and though the patient was in the office during the three-year period, the doctor bills for a new patient exam.
It doesn’t matter if they have a new injury or you get paid more for a new patient code, they are considered an established patient. (Codes 99211-99215). In this case, billing the new patient code is not only illegal, it’s fraud. Fraud means that if you get caught you could go to jail.
The rule of thumb here is don’t go to jail; the food sucks and you always have a bad view!
Another concern with new patient E/M codes is billing the highest code, the 99205. As a chiropractic physician, you can never meet the requirements for this code and billing it will only get you in trouble. This code will guarantee that your records will get looked at closely and increases the likelihood of an audit.
It could also be seen as fraud, so the same rule of thumb applies here, “Don’t go to jail.”
The level of the code billed is dependant on three key factors. The level of Exam, the level of History and the level of Medial Decision Making. Each level is determined by certain factors such as the number of complaints and how extensive a history you take that is relevant to the patient’s complaints.
There isn’t enough room in this article to cover all the requirements, but maybe I can cover each one individually in future post. Until then, remember it’s your responsibility to know how to bill the correct E/M code.
The “Chiropractic Compliance Made Easy” program is the most complete course on office compliance and includes how to document the correct E/M code.
All The Best,
Dr. John Davenport
Chief Compliance Officer