Download Reference Documents

These Reference Documents are helpful tools as you continue to get familiar with and follow the rules of documentation of initial visits. First, you’ll find the official document from the American Medical Association (AMA) laying out the new 2021 Evaluation and Management (E/M) updated guidelines for coding your E/M services. This document clearly lays out and establishes the new guideline which are to be used to correctly code your E/M services. Download and review these guidelines to reference when documenting and coding your E/M services.

The sample included here from the Colorado State Board, gives the record keeping requirements including the minimum documentation expectations for this state. This resource is meant to be an example of what should be available in each state. We recommend that you locate and get familiar your state board minimum documentation requirements.

We also included a Chiropractic specific resources which includes algorithms, for common patient presentations and situations to guide you as a how-to regarding management of episodes of care, documentation recommendations, and several practice specific definitions. As you read through this article, take the time to look at the algorithms and track what a path of acute care looks like.

Be sure to download, study, and save these invaluable tools as part of your documentation training.

AMA CPT E/M Code and Guideline Changes
Sample Board Record Keeping Requirement
Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain