Prolonged Service Codes

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...
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Documentation of Initial Office Visit Assessment and Diagnosis Reference Documents

Download Reference Documents The first two resources listed here are neck and low back diagnosis tables pulled, with permission, from the Sousa textbook. Refer to these tables to ensure your doctoring is leading to the most accurate diagnosis codes and that you have the findings to verify the codes you are using. In the third...
OOPS, this page contains content reserved for KMC University members. We’d love to welcome you to the KMC University family because there is an amazing amount of helpful content in the trainings and resources of the KMC University Library. Click here to learn more.

Document Medical Decision Making (MDM) with Ease

Document MDM The new Evaluation and Management (E/M) coding rules that went into effect at the beginning of 2021 led to many questions that require clarification on what documentation should look like, as the coding is now based on Medical Decision Making (MDM) or Time. One of the main reasons for the change to this...
OOPS, this page contains content reserved for KMC University members. We’d love to welcome you to the KMC University family because there is an amazing amount of helpful content in the trainings and resources of the KMC University Library. Click here to learn more.

Initial Visit Documentation Reference Documents

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