Chiropractic E/M Coding Guide Part 1: New vs. Established Patients (99201–99215 Explained)
A patient walks into your clinic with acute low back pain. You evaluate, adjust, and document appropriately—but then pause: Is this a 99203 or a 99213? That single decision can mean the difference between proper reimbursement and audit risk.
Accurately coding Evaluation and Management (E/M) visits is essential for chiropractors. Correct coding ensures compliance, supports reimbursement, and strengthens patient documentation. One of the most common areas of confusion is distinguishing between new and established patients, which directly affects coding, documentation, and payer audit risk.
In this first part of a four-part series, Dr. Evan Gwilliam, Senior Vice President at Practisync, breaks down the practical differences and provides actionable guidance for coding new vs. established patients.
E/M Coding for New Chiropractic Patients
A new patient is someone who has not received professional services from your practice or another chiropractor in the same group in the past three years.
New patient visits generally require a comprehensive history, detailed examination, and thorough medical decision-making (MDM). Encounter times can range from 10 to 60 minutes, depending on complexity. Even if the visit focuses on manual therapy, proper documentation of evaluation and assessment is critical to justify the E/M level. CPT codes for new patients typically fall in the 99201–99205 range.
E/M Coding for Established Chiropractic Patients
Unlike new patients, an established patient has been seen at your clinic within the past three years.
Documentation for these visits can be problem-focused or detailed, reflecting updates to the patient’s history, response to treatment, and plan-of-care adjustments. MDM is usually lower, and visits tend to be shorter (5 to 40 minutes). Common CPT codes for established patients include 99211–99215. Proper documentation ensures accurate coding and reduces audit risk.
Quick Reference: New vs. Established Patient E/M Coding
| New Patient | Established Patient | |
|---|---|---|
| Definition | Not seen in the past 3 years | Seen within the past 3 years |
| Documentation | Comprehensive history + detailed exam | Problem-focused or detailed updates |
| Complexity | Low–High | Low–Moderate |
| Encounter Time | 10–60 min | 5–40 min |
| Common CPT Codes | 99201–99205 | 99211–99215 |
*Audit risk: Payers frequently audit E/M codes due to inconsistent documentation, especially when higher-level codes are used without clear MDM support.
2021 E/M Coding Updates: What Chiropractors Need to Know
The E/M coding guidelines were significantly overhauled in 2021, with minor updates in 2023 and 2024. The goal, according to the AMA, was to focus documentation on how providers think and care for patients rather than rigid checklists:
“…documentation for E/M office visits will now be centered around how physicians think and take care of patients and not on mandatory standards that encouraged copy/paste and checking boxes.” (1)
The changes were designed to simplify documentation, reduce note bloat, and allow providers to focus more on patient care. The most important principle remains medical necessity. Code selection should reflect the complexity of the patient’s condition—not just whether the notes include all guideline elements.
The biggest change in 2021 was the removal of History and Examination as factors for determining the E/M level. Instead, code selection now depends on medical decision-making (MDM) or the total time spent performing the service. These topics will be explored in more detail in parts 2, 3, and 4 of this series.
FAQs
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A patient is considered established if they’ve received professional services from you or another provider in your clinic group within the past 3 years. If not, they are considered a new patient.
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No. If the provider is part of the same clinic group and shares the same specialty, the patient is still considered established.
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No. Patient status is based on the provider relationship within the past 3 years, not the condition being treated.
Conclusion
Accurately distinguishing between new and established patients is key for proper E/M coding. Chiropractors should verify patient status, tailor documentation to the visit type, and fully capture history, exam, and medical decision-making.
Want to eliminate E/M coding guesswork? ChiroUp’s EHR helps guide documentation and coding based on clinical inputs, helping you stay compliant and efficient. See how it works in a quick walk-through with our team.
This is Part 1 of a 4-part E/M Coding Mastery Series. Stay tuned for the following parts to be released over the next few months:
Part 2: Medically Appropriate History and Examination
Part 3: Coding Using Time
Part 4: Coding Based on Medical Decision Making
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American Medical Association. CPT® evaluation and management. American Medical Association. Link
