Evaluation and management (E/M) codes are the most widely used category in medical coding, so it’s no surprise that they apply to dozens of specialties including chiropractic practices. Chiropractic E/M coding can be tricky for those who aren’t familiar with the field, but with a little bit of practice, you will be able to master them in no time.

To start, know that chiropractic visits always start with a consultation visit. Unless a chiropractor completely ignores the protocols of their job, they will always ask about the patient’s complaints and formulate a plan of care before diving into cracking necks and providing other treatment. This means that there should always be an initial encounter for the consultation, followed by additional encounters for the actual treatment.

As a rule, chiropractic E/M coding rarely strays into intense levels of care. High-level E/M codes such as 99204 (New patient, comprehensive history, comprehensive examination, medical decision-making of moderate complexity) and 99215 (Established patient comprehensive history, comprehensive examination, medical decision-making of high complexity) aren’t often appropriate, as patients don’t typically present with problems that have high risks of morbidity.

Without a review of systems, the highest level of care that should be reported is 99202 (New patient, expanded problem focused history, expanded problem focused examination, straightforward medical decision-making) or 99213 (Established patient, expanded problem-focused history, expanded problem-focused examination, medical decision-making of low complexity). The level of a consultation code may increase, however, if the patient presented with a request for evaluation written by a credible outside source.

When working with chiropractic E/M coding, pay special attention to the level of the consultation so that you can assign the appropriate level of code. If you encounter any questions during the coding process, always be sure to query the physician rather than making assumptions from the documentation alone.