Question

An insurer told me that chiropractors cannot bill 99204 or 99214 because those exams "require a level of decision making that would typically only occur in an emergency room." Is this true? Do I have any recourse?

Answer

This assumption can be challenged, but the provider would need the help of a certified coder if they want to start a fight.

The level of decision making for level four exams is "Moderate Complexity". This requires that the documentation support 2 of the 3 criteria for Medical Decision Making.

The Emergency Room is not mentioned as in any of those three in order to qualify as "Moderate Complexity". And if it did in one of them, it would not matter because only 2 of the 3 criteria must meet or exceed the requirements.

Furthermore, a 99214 is much easier to reach than a 99204 because the Medical Decision Making can be thrown out entirely since only the History and Exam must meet or exceed the criteria for established patients.

Additionally, in some cases, none of the Key Components matter because the encounter could be a time override due to counseling rather than time spent doing the History, Exam, or Medical Decision Making.

It may be that the insurer really meant to refer to Nature of the Presenting Problem (i.e. medical necessity), which can trump the three Key Components. The Presenting Problem must be "moderate to high" for level four exams. Part of the criteria for a "moderate" type of Presenting Problem is "increased probability of prolonged functional impairment".

The DC needs to be sure to document this for E/M codes that have a moderate type of Presenting Problem to make sure their E/M codes are not denied for this reason.

Having said this, level four exams should not be routine. They would be expected to be reserved for only the most complex cases in a chiropractic setting.

ChiroCode has a recording that summarizes E/M coding for DCs and includes a laminated, color, E/M audit card. Or, see the summary in chapter 5.3 of the 2017 ChiroCode DeskBook.