The Diagnosis is Not an Assessment Chiropractors often confuse a diagnosis with the assessment portion of an initial visit note. The diagnosis and the treatment plan are just components of the assessment. The assessment, coupled with the information gathered while taking the patient’s history during examination, and his/her working diagnosis, reveals more about the patient…

Far too often, we find a fancy code (maybe a new code) and want to find a way to charge for it. This is completely backward. Documentation must drive coding. This simple visual reminder outlines the process of starting with the documentation and coding from there. Utilize this concept to re-enforce the dependency that each…

Guidelines, guidelines everywhere, and not a clear understanding to be found. As you learn about the ins and outs of documentation and diagnosis coding, you must be aware of where the requirements come from. There are continual changes in the guidelines and as a provider you need to know who is making the rules to…

 Reference Document If you would like to dive into additional detail on current E/M coding, you can review the updated AMA’s release of their Office or Other Outpatient (99202-99215) and Prolonged Services (99243, 99244, 99245, 99417) Code and Guideline Changes. It contains definitions used within the CPT code descriptions, full CPT code descriptions, charts, and…

Add-On Prolonged Service Codes Prolonged Services codes are add-on Evaluation and Management (E/M) codes used to indicate the time component has exceeded the Current Procedural Terminology (CPT) time codes available. As add-on codes to 99205 and 99215, these codes report E/M coding that is extended time beyond the defined new and established patient codes. The…

The following examples are meant for illustration and educational purposes only. Actual patient encounter experiences and documentation dictate the selection of the appropriate Evaluation and Management Code using total time from the day of the encounter. Scenario 1-New Patient Patient presented at first visit with inches of paperwork from prior chiropractic care over the last…