Documenting Clinical Findings and Diagnosis

3 CE Credits

* CE Credits are for Doctors of Chiropractic only

** Please note this course is only approved in the state of Texas through 7/31/25.  After that there will be no CE available in TX.

Master E/M Documentation for 99202–99205

Build defensible evaluations, accurate diagnoses, and ICD-10 coding that holds up to scrutiny.

If you want your Evaluation & Management documentation to meet current coding requirements, support medical necessity, and clearly justify your care plan, this 3-hour training delivers a step-by-step system you can implement immediately.

✔️ Improve accuracy in diagnosis and prognosis
✔️ Support appropriate E/M code selection (99202–99205)
✔️ Capture all clinically relevant conditions and treatment areas
✔️ Create ICD-10 codes that reflect causality and sequelae

[Enroll Now] (Primary CTA)
[Download Course Outline] (Secondary CTA)

Why This Course Matters

E/M coding is more than a number. It’s the documentation story that supports:

• Triage and clinical decision-making

• The “why” behind your treatment plan

• Accurate diagnostic justification

• Defensible coding and billing

• Proper use of re-evaluations as conditions evolve

This course is designed for chiropractors who want documentation that is clear, complete, compliant, and clinically persuasive.

What You’ll Learn (3 Hours)

Hour 1 — History + Triage: Start with the Right Clinical Framework

Learn how to use the history portion of the E/M process to determine triage and clinical direction using:

• Chief complaints and symptom behavior

• Systems review (ROS)

• Past medical history

• Family history

• Social history

• Surgical history

Outcome: You’ll know what needs to be documented—consistently—to support the complexity of your encounter and the medical necessity for your next steps.

Hour 2 — Exam + Testing: Turn Findings Into Defensible Diagnoses

Learn how to correlate key exam elements and test results to determine:

• Accurate diagnosis

• Prognosis

• Treatment plan development

We’ll cover how to integrate findings from:

• Vitals

• Orthopedic testing

• Neuromuscular examination

• Basic imaging

• Advanced imaging (as clinically indicated)

• Electrodiagnostic testing (as clinically indicated)

Outcome: Your exam and testing will clearly connect to your diagnosis and plan—so your documentation reads like evidence, not opinion.

Hour 3 — ICD-10 Coding: Build Complete, Compliant Diagnosis Lists

Learn how to create accurate ICD-10 codes, including:

• Causality coding

• Sequela codes

• Ensuring all uncovered pathology is included

• Ensuring every treated body region has a corresponding diagnosis

• Understanding re-evaluations and when diagnoses must be updated

Outcome: Your coding will reflect the full clinical picture and reduce vulnerability from missing, mismatched, or incomplete diagnoses.

Course Objective

Document E/M encounters that meet coding requirements for:

99202 • 99203 • 99204 • 99205

By the end of this training, you will be able to produce documentation that meets the required coding elements and decision-making structure expected in a compliant Evaluation & Management encounter.

Who This Is For

This course is ideal for:

• Chiropractors wanting to strengthen E/M documentation and coding

• Clinicians looking to improve diagnostic defensibility

• Practices training associates on structured evaluation workflows

• Providers wanting documentation that supports medical necessity and treatment justification

If you’re tired of documentation guesswork and want a repeatable framework, this is for you.

Instructor 

Mark Studin, DC, FPSC, FASBE(C), DAAPM

Chiropractor

Mark Studin brings extensive clinical and educational expertise in documentation, diagnosis, and defensible E/M processes. This training reflects real-world workflow—not theory—so you can apply it directly in practice.

Key Takeaways 

By the end of this course, you’ll be able to:

✅ Triage properly using history + system review
✅ Connect exam findings to diagnosis and prognosis
✅ Document test results with clinical relevance
✅ Build complete ICD-10 coding that matches treated regions
✅ Use re-evaluations properly to update diagnosis and ensure ongoing accuracy
✅ Create documentation that supports 99202–99205 requirements

Ready to tighten your E/M documentation and strengthen coding defensibility?

Get the full framework in 3 hours—then implement it on your next evaluation.

[Enroll Now]
[Download Course Outline]