E & M Coding: Point of Controversy

Controversy is brewing. The Texas Chiropractic Association has adopted recommendations for use of the Evaluation and Management (E & M) codes. The American Chiropractic Association (ACA) has also adopted recommendations. For the most part they are in agreement with each other. Both the TCA and the ACA are in agreement that the Physician's Current Procedural Terminology (CPT-4) should be used as, "...language and coding to uniformly describe and report their services, except where specifically required to do otherwise by state or federal statute, rule, regulation, or private contract."^1,3 Further agreement lies in the position that a uniform and consistent means of coding be utilized to report out all services performed by chiropractic physicians.^2,4

The one and only difference is whether the reporting of manipulation should be done as an integral part of the E & M code (TCA position),4 or should it be reported as a separate and distinct service using 97260 and/or 97261 (ACA position)?⁵

The ACA's position is supported by two different positions. First, that "The ACA agrees that this separation is consistent with the intended use of these new services descriptors."⁵ Second, that, "There should be no difference in the level of documentation and reporting requirements for one physician provider over another. If it is appropriate for medical providers to specifically describe the nature and extent of the services they administer to a patient, it should be no less important for the chiropractic provider."⁶ Further support is claimed in a cited "national survey of chiropractic attitudes ... CPT Code Survey, Association Research Inc., Rockville, MD. January 1993."⁷

The TCA has based its position on the fact that, "The levels of E & M services include examination, evaluations, treatment, conferences with or concerning patients, preventative pediatric and adult health supervision, and similar services. The levels of E & M services encompass the wide variations in skill, effort, time, responsibility, and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E & M services may be used by all physicians."⁸ Further support is shown: "Some of the listed procedures are commonly carried out as an integral part of total service, and as such, do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to other services, it may be listed as a 'separate procedure.' Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be reported as a separate procedure."⁹

There are a few questions that must be asked to ponder this difference of opinion. First, where does the palpatory examination end and the actual performance of the adjustment begin? Is there a definite end/beginning point? Does the palpatory examination extend into the adjustment? Can a true chiropractic adjustment be performed without any palpatory contact? Second, are the history, exam, and decision making an integral part of the adjustment? Can each service be provided independently of the other? Is the adjustment commonly carried out as an integral part of a total service?

The palpatory examination does continue into the actual performance of the adjustment. If it did not, how would the doctor know that the correction had taken place to the extent needed to gain relief for the patient? While a history, examination and decision making can take place independently of each other, there is no school which promotes the performance of the adjustment without palpating the spine to determine the level of or presence of fixation or subluxation. Any attempt to "adjust" in this manner would not be a true chiropractic adjustment. The specific nature of the adjustment demands that clinical decisions be made as to level needing correction, line of drive, velocity and amplitude of force, and levels not needing correction. Even the decision to treat that particular patient on that particular visit is a decision and a responsibility that is taken on for every patient that walks into your office. This is the way TCA answered these questions.

In a good faith effort, the TCA E & M Coding Committee will request time on the agenda for the January 20, 1994 ACA Board of Governor's meeting to resolve these differences.

We are presenting this information for the entire profession to review, comment on, ask questions about, and even to criticize. This is the scientific method: hypothesize, investigate, report, scrutiny, and revision as needed. We invite your comments, questions and/or criticisms. They may be sent to:

References

1. TCA, E/M Coding Committee Report to Board of Directors. Adopted April 3, 1993.

    

2. TCA, E/M Coding Committee Report to Board of Directors. Adopted in resolution Feb. 6, 1993.

    

3. ACA, Recommendations for Describing Chiropractic Services Using CPT-1993. ACA 1993, p.3, #1.

    

4. Ibid, p.3, #2-3.

    

5. Ibid, p.6.

    

6. Ibid. p.7.

    

7. Ibid, p.5.

    

8. AMA, CPT-4 1993 Physician's Current Procedural Terminology. AMA 1992, p.3.

    

9. Ibid, p. 547.