Complete Story
11/19/2025
Outpatient Evaluation & Management (E/M) Documentation for Chiropractic Offices: What You Need to Know
Authored by: Stephanie Davidson, Michigan Assn of Chiropractors - Insurance Director
Chiropractic offices frequently perform and bill Evaluation & Management (E/M) services, as well as treatments, known as “medically necessary” services, such as active spinal chiropractic adjustments. Regardless of the service billed, medical necessity must be clearly supported in the patient’s documentation, and payers look primarily at the E/M record to determine this.
Why?
Because the E/M encounter is where you tell the patient’s clinical story: the history, the exam, and, most importantly, the clinical reasoning behind your diagnosis and treatment plan. This visit acts as “Chapter 1” of the patient’s episode of care and establishes the medical necessity for any subsequent services you provide.
In 2021, the AMA significantly revised the E/M documentation guidelines, shifting the focus to Medical Decision Making (MDM) or Total Time, eliminating the old 1995/1997 history/exam scoring rules. This change places a much greater emphasis on the medical necessity documented during the E/M service.
If your documentation does not support the elements required for the E/M level you billed, you are at risk for downcoding or recoupment during an audit. Even when a payer does not reimburse for E/M services, this documentation is still essential, as it establishes the medical necessity for all billed and payable services.
The Components of an E/M Service
Every Evaluation and Management encounter still consists of three core components:
- History
- Examination
- Medical Decision Making (MDM)
Under the 2021 outpatient E/M rules, history and exam must still be documented when medically appropriate and relate to the care provided, but the extent of those elements no longer determines the E/M code. Code selection is now based only on:
- Medical Decision Making, or
- Total Time spent on the date of service
How to Select the Level of Service (LOS): Two Options
Option 1: Medical Decision Making (MDM)
The complexity of your clinical reasoning determines the level.
The 3 Elements of MDM:
- Problems Addressed – Number and complexity of problems evaluated
- Data Reviewed/Analyzed – Records, tests, and information reviewed or ordered
- Risk of Management – Risk of complications, morbidity, or mortality of the management decisions
To determine and bill the correct E/M level (99202–99215), providers must use the AMA MDM Matrix together with the accompanying Definitions. At least two of the three MDM elements must meet or exceed the requirements for the selected level.
The Matrix shows the thresholds, but the Definitions explain what each term actually means, such as what qualifies as a “stable” problem, what counts as “independent interpretation,” or how to classify risk. Both pieces are essential for selecting the accurate level of service.
Note: If you are taking, interpreting, and billing for an X-ray in your own office, this does not count as ordering or reviewing a “unique test” for purposes of MDM. Tests that are performed and billed separately may not be counted in the Data element.
Option 2: Total Time Spent on the Date of Service
Instead of MDM, providers may select the LOS based on the total time spent on the calendar date of the encounter.
Billable Time May Include:
- Preparing to see the patient
- Reviewing history or external records
- Performing a medically necessary exam
- Counseling or educating the patient/family
- Referring patient for outside tests or procedures
- Coordinating care
- Documenting the visit
- Independently interpreting results (when not separately billed)
Time That May NOT Be Counted:
- Work for other services that are billed separately (i.e., work performed during the chiropractic manipulative treatment or in taking of the x-ray)
- Travel
- General education not related to patient management
CPT Codes & Time Ranges:
New Patients
- 99202: 15–29 min
- 99203: 30–44 min
- 99204: 45–59 min
- 99205: 60–74 min
Established Patients
- 99212: 10–19 min
- 99213: 20–29 min
- 99214: 30–39 min
- 99215: 40–54 min
Important Note on Scheduled Time vs. Billable Time:
Just because a “30-minute E/M visit” is scheduled in your appointment system does not mean the encounter automatically qualifies for CPT 99203, or any other time-based E/M level.
The scheduled duration and the actual, medically necessary, documented provider time are not the same.
Only the provider’s actual time spent on qualifying activities on the date of service may be counted. To support a time-based E/M level, the documentation must clearly show:
- The total time spent
- The medically relevant activities performed
- That the provider performed those activities on that date
If any of these elements are missing, the higher time-based code is not supported, even if a 30-minute visit was scheduled.
Documentation Requirements
If Billing Based on MDM
- Clearly describe problems addressed, data reviewed, and risk.
- Show clinical reasoning supporting medical necessity.
- No time documentation required.
If Billing Based on Time
- Document total time or start/stop times.
- List the qualifying activities performed.
- Only include work completed on the calendar date of the encounter.
In chiropractic care, the E/M service sets the stage for the entire episode of treatment. A clear history, relevant examination, and well-reasoned clinical plan make it easy to establish medical necessity for spinal adjustments and any adjunct services. Consistent, detailed E/M documentation not only satisfies payer expectations but also reinforces the quality, purpose, and direction of your chiropractic care.
