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Describing Congruence Between Procedural Codes and Medical Record Text in Veterans Health Administration Chiropractic

Samuel M Schut¹, Sarah E Graham², Anna R Sites³

¹Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, Ohio; Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, Ohio.

Journal of Manipulative and Physiological Therapeutics

|September 29, 2025

Summary

Chiropractic care in the Veterans Health Administration shows high congruence between Current Procedural Terminology (CPT) codes and documented procedures. However, limitations exist in using CPT codes alone, particularly regarding patient education.

Keywords:

Chiropractic Current Procedural Terminology Documentation Health Care Veterans Health

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Area of Science:

Chiropractic care
Health informatics
Healthcare coding systems

Background:

Accurate coding is essential for healthcare reimbursement and quality assessment.
Understanding the alignment between procedural codes and clinical documentation is crucial for healthcare systems.

Purpose of the Study:

To assess the agreement between Current Procedural Terminology (CPT) codes and the text documentation of therapeutic procedures in chiropractic notes within the Veterans Health Administration (VHA).

Main Methods:

A manual chart review of 1000 randomly sampled VHA chiropractic visits from 2017-2018.
Extraction of CPT codes and documented procedures, excluding evaluation and management codes.
Application of a novel rating system to evaluate congruence, with analyses conducted including and excluding patient education codes.

Main Results:

Analysis of 808 included notes revealed high overall congruence: 29.6% completely congruent and 63.5% partially congruent.
Excluding patient education codes from 790 notes showed 51.1% complete congruence and 41.4% partial congruence.
These results indicate generally high agreement but highlight variability, especially concerning patient education.

Conclusions:

Congruence between CPT codes and chiropractic procedure documentation in the VHA is generally high.
The study identified limitations in solely relying on CPT codes to represent VHA chiropractic care, particularly the underrepresentation of patient education.
Further refinement of coding practices may be needed to fully capture the scope of chiropractic services provided.