Chiropractic E/M Counseling Record

Counseling and its associated time needs to be identified and documented. This form will serve as documentation, or as a guide to your dictation.

1. Record your start and end times. This is critical because coding by Counseling is based on time. 
2. Document any History, Exam, and Medical-Decision-Making (H-E-M) service at the top of the form. Space here is limited since H-E-M services performed during Counseling are usually minimal. 
3. Document the Counseling and/or Coordination of Care (C-C) service. Subcomponents are taken directly from official CPT guidelines, and are in the same sequence. If the lines on the form are too short, make an attachment and reference it (e.g., you might have one or more pages of instructions for risk management, exercises or diet, etc.). Document any points discussed with the patient. You do not have to complete all items, only those that are relevant.
4. Also, document any Coordination of Care with other providers or agencies that was done during the patient encounter.
5. Calculate and record H-E-M and C-C times in the time summary box.
6. Select the code that is nearest to the total doctor-patient intra-service time, and append the modifier -25 for Significant, Separately Identifiable (SSI) E/M services.

Attach your E/M counseling record (or your dictation of it) to your claim form (1500 or other). If allowed by your payer, give an explanation in Box 19 such as: “Modifier -25 is for E/M Counseling, for 30 minutes,” or “See attached E/M Counseling report.”