I am pretty confused about E&M level coding for this situation. My DC sees a new patient. Her records, even though in the SOAP format, are not comprehensive enough to warrant the 99204 that she is billing. However, for the counseling session before the adjustment, she spends at least 30 of the 45-50 minutes explaining the theory of chiropractic, the function of both spine and meninges, the insults to the system such as chemicals, etc. So...does she bill the 99204 noting the counseling time spent in the notes, and not need to do a comp exam...or should she bill, say, a 99202 with a prolonged service add-on code? I understand 99204 to mean severe risk to morbidity and/or mortality. Please help. Thank you.
