E/M Services, Modifier 25 and Chiropractic: Binding Standards vs. Best Practices

In recent years, healthcare providers of many specialties have experienced substantial reimbursement challenges related to Modifier 25. From pre-payment audits to fee reductions when modifier 25 is used, third-party payers across the United States have recently embraced a wide variety of strategies to reduce costs associated with modifier 25. As many chiropractors have experienced first-hand, our profession has not been exempt from these policies and the challenges they present.

Dr. Christopher

With his extensive knowledge and experience in matters of coding and documentation, Matthew Christopher, DC, MBA, CPC, CPMA, CPCO, CPB, CCPC, will help chiropractors better navigate Modifier 25 during his ACA Engage 2024 presentation, “E/M Services, Modifier 25, and Chiropractic: Tips for Documenting, Coding, Billing, and Appealing Inappropriate Denials.” Look for it on the Engage 2024 schedule and register today to attend!

Below, the ACA Blog learns more about Dr. Christopher and what attendees can expect:

How is the topic you are presenting at Engage 2024 relevant to today’s chiropractor?

Dr. Christopher: While chiropractic manipulative treatment (CMT) includes an evaluation of the patient, there are situations where an additional, more extensive evaluation and management (E/M) service is appropriate. Modifier 25 indicates that the E/M service is separate and distinct from the usual pre-service, intra-service, and post-service work associated with the manipulation or other procedure(s) performed on that encounter.

Unfortunately, the nuances of when to use modifier 25 on a chiropractic visit are sometimes plagued by vagaries. The application of the rules also sometimes differs from one third-party payer to another. The diverse and occasionally ambiguous nature of these rules has led to much confusion. It has also created ample opportunity for abuse. And this abuse is a two-way street. Some third-party payers and reviewers deny almost all established patient E/M codes on the same date as CMT, even when modifier 25 is appropriately appended. On the other hand, there is a small subset of chiropractors who bill an E/M code on almost every treatment visit, even when this is contrary to binding payer-specific policies. In our time together, we will discuss how generally accepted coding practices do not support either of these extreme positions.

Fortunately, a basic understanding of a few key concepts related to modifier 25 will make it much easier for chiropractors to navigate the healthcare reimbursement system and manage risks in their practice. These discussions will empower providers and equip them with skills and resources to implement in practice the following week.

What makes you an expert in this area?

Dr. Christopher: I am a chiropractor, peer reviewer, and Certified Professional Coder (CPC) with an MBA in Healthcare Administration. I also have additional compliance, auditing, billing, and specialty coding certifications.

My practical application of these concepts has primarily occurred on two fronts. First, I have extensive experience treating patients in private chiropractic practice, consulting with chiropractors, and overseeing billing for up to five providers at a time. Second, I have broad experience consulting and performing peer reviews for insurers, regulatory bodies, and attorneys. I have conducted many thousands of clinical and coding reviews for Medicare, Medicaid, commercial insurance, auto, and worker’s compensation cases.

I also have the privilege of applying my specialized skills and knowledge through service to the profession. I have contributed to insurance industry clinical practice guidelines and coding guidance for state and national professional associations. For example, I made substantial contributions to the member-only ACA coding guidance on “CMT and E/M Reimbursement Solutions.”

I also serve on the Peer Review Committee of the Kentucky Board of Chiropractic Examiners and volunteer many hours in my positions on the American Chiropractic Association’s Health Policy & Advocacy Committee and Code Utilization and Application Subcommittee. Lastly, I have served on the Kentucky Association of Chiropractors’ Insurance Relations Committee.

Not only do I have knowledge and practical experience related to modifier 25, but I also have more than 10 years of experience communicating concepts like this to healthcare professionals. My teaching repertoire includes continuing education sessions on medical necessity, coding, and healthcare fraud across a large spectrum of the healthcare system. I have taught groups of chiropractors, expert witnesses, attorneys, medical coders, law enforcement officials, and insurance industry special investigators, to name a few.

What is one takeaway from your presentation/topic that Engage 2024 attendees will not want to miss?

Dr. Christopher: Most importantly, providers will learn to distinguish between binding standards and best practices. Upon considering the binding standards that apply to an encounter, we will discuss how to assess and manage the risks associated with modifier 25 while also accounting for best practices. We will explore this critical concept in the context of modifier 25, but it also applies to many other decisions related to coding, medical necessity, and reimbursement rules.

Regarding modifier 25 specifically, we will discuss clinical practice guidelines that address the need for periodic patient assessments throughout a chiropractic treatment plan. With these clinical concepts as a foundation, participants will delve into crucial coding and reimbursement rules that may apply to E/M services performed on the same date as other procedures performed by chiropractors. We will explore the practical applications of these concepts to chiropractic documentation, coding, and billing. Finally, we will discuss some critical components of an effective and efficient appeals process for inappropriate denials of E/M services.

How will what attendees take away from your presentation make them better doctors?

Dr. Christopher: We will dive into what the peer-reviewed literature says about when evaluations are clinically appropriate. This discussion will also provide a better understanding of how periodic evaluations can help demonstrate the medical necessity of chiropractic services to third-party payers and regulatory bodies.

Members of the ACA specialty councils are instrumental in developing ACA’s cutting-edge education programming at Engage 2024. What benefits have you personally experienced from being a specialty council member?

Dr. Christopher: Above all, the Council on Forensic Sciences is a community. The relationships I have built with experts and consultants of various specialties have greatly influenced my personal and professional growth. Of course, this community is at its best when we meet at our conference each fall in Oak Brook, Ill.. However, the conversations continue throughout the year.

I also find value in the Journal of Chiropractic Medicine subscription, the newsletters, CE discounts, and the other membership benefits. However, the community of evidence-based clinicians, expert witnesses, and professional coders is worth the cost of membership.


The American Chiropractic Association’s (ACA) annual meeting, ACA Engage, will take place Jan. 24-27, 2024, in Washington, D.C. The event offers top-notch education (up to 12 CE credits available), networking opportunities, presentations from clinical experts, panel discussions, and social events. You won’t want to miss ACA Engage 2024! Learn more and register.