E/M Documentation Essentials for Massachusetts Chiropractors (MCS)
Massachusetts Chiropractic Society (MCS) member offices frequently perform and bill Evaluation & Management (E/M) services, along with medically necessary treatments such as active spinal chiropractic adjustments. Regardless of the service billed, medical necessity must be clearly supported in the patient’s documentation, and payers rely primarily on the E/M record to determine this.
Why the E/M Visit Matters
The E/M encounter tells the patient’s clinical story: their history, examination findings, and—most importantly—the clinical reasoning behind your diagnosis and treatment plan.
This initial visit serves as Chapter One of the patient’s episode of care and establishes the medical necessity for all subsequent services billed, including chiropractic manipulative treatment (CMT).
2021 AMA Guideline Updates
In 2021, the AMA revised E/M documentation guidelines, shifting code selection to:
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Medical Decision Making (MDM), or
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Total Time spent on the date of service
This eliminated the old 1995/1997 scoring requirements for history and exam elements. While you must still document a medically appropriate history and exam, these no longer determine the E/M level.
Because Massachusetts payers—including commercial plans, Medicare, and MassHealth MCOs—rely heavily on medical necessity documentation, accurate E/M notes are essential even when a payer does not reimburse for E/M services separately.
If documentation does not support the level billed, Massachusetts providers remain at risk for downcoding or recoupment during audits. Clear E/M documentation protects both the provider and the patient.
Components of an E/M Service
Each E/M encounter includes:
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History
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Examination
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Medical Decision Making (MDM)
Under current rules, the extent of the history and exam is based on what is medically appropriate—not a checklist.
E/M level selection now depends solely on:
Option 1: Medical Decision Making (MDM)
MDM complexity is based on three elements:
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Problems Addressed (number & complexity)
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Data Reviewed/Analyzed
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Risk of Management
To bill the correct code (99202–99215), at least two of the three MDM elements must meet or exceed the requirements for a given level.
Important for Massachusetts chiropractors:
Tests performed and billed separately—such as in-office X-rays—cannot be counted as “unique tests” in the Data element for MDM scoring.
Option 2: Total Time Spent on the Date of Service
Billable time may include:
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Preparing to see the patient
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Reviewing history or external records
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Performing a medically necessary exam
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Counseling or educating the patient
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Care coordination
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Referrals and documentation
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Independent interpretation of materials not billed separately
Cannot be counted:
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Time spent on services billed separately (e.g., CMT, X-rays)
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Travel
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Non-clinical patient education
CPT Time Ranges
New Patients
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99202: 15–29 min
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99203: 30–44 min
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99204: 45–59 min
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99205: 60–74 min
Established Patients
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99212: 10–19 min
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99213: 20–29 min
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99214: 30–39 min
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99215: 40–54 min
Scheduled time ≠ billable time
Massachusetts auditors focus on actual, documented, medically necessary time—not the appointment slot length.
Documentation must show:
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Total time
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Activities performed
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Date of service
Documentation Requirements
If Billing Based on MDM
Your note must:
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Clearly outline problems addressed, data reviewed, and risk
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Show clinical reasoning
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Establish medical necessity for all services that follow
No time documentation required.
If Billing Based on Time
Your note must:
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Document total time or start/stop times
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List qualifying activities performed
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Include only time spent on that date
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Demonstrate that provider (not staff) completed those activities
Why This Matters for Massachusetts Chiropractors
Within the Commonwealth, payers highly scrutinize chiropractic documentation—particularly E/M notes—as part of medical necessity determinations.
Strong, clear E/M documentation:
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Protects MCS members during payer audits
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Demonstrates clinical appropriateness
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Supports reimbursement for CMT and adjunct services
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Establishes the treatment plan and expected outcomes
A well-constructed E/M visit sets the tone for the whole course of care.
