Initial Visit - Billing for Appropriate Level of Service

Be certain to bill for the services you provide. For example: A patient presents with a complaint of pain in one region. Through your examination, you find evidence of subluxation in four regions of the spine, which you adjust. Therefore, you should document and bill for adjusting four regions (98941).

Note that down coding, up coding, or billing with a single code regardless of the patient's condition, are incorrect practices, even if doing so gets your claims paid. These billing practices can cause you to look different from other providers and may subject you to other types of review.

Bill for and document the services you render at the level you provide them.