EM Coding Alert

Question: We have traditionally used the 1995 E/M guidelines when making our code selections, but our office manager just went to a seminar where she heard that the 1997 guidelines were better suited for our specialty when it comes to the exam. Is this accurate? Will it make a big difference for us to change?

New York Subscriber

Answer: Both sets of guidelines help you determine which exam level you performed: Problem-focused, expanded problem-focused, detailed, and comprehensive. But the exam element is the most significant difference between the two sets of guidelines.

1997: The 1997 guidelines include specific physical exam elements that must be addressed in the documentation, both for a general multisystem exam and for single organ system examinations. If a physician addresses elements other than those specified in the guidelines, the physician will not necessarily receive credit for those elements in the level of service when using 1997 guidelines. Also, if the language pertaining to an exam element included in the documentation differs from the language included in the guidelines, an auditor who has not had much clinical experience may inadvertently exclude the element from being credited in the level of service.

1995: The 1995 guidelines are much more general and, therefore, much less restrictive in a way. They allow the GI physician to make any comment in any of the organ systems he examines. What the physician examines within the systems and the wording he or she chooses to document are ultimately decided by the physician.

You don’t have to pick one set of guidelines and stick with them every time you code an E/M service. You can switch between 1995 and 1997 from one service to the next, choosing whichever set of guidelines is most advantageous for each encounter.

Essential: The key, however, is that you have to use either 1995 or 1997 exam guidelines for a single encounter, with one exception. “For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter,” CMS says in its MLN Matters document, Evaluation and Management Services. “However, beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service,” the document notes. The key benefit of the 1997 history at the detailed level is that describing the status of 3 more chronic conditions can qualify for a detailed exam, rather than having many observations about the chief complaint. Most EHR systems “count” physical exam elements reflecting 1997 guidelines and cannot “count” physical exam details if the 1995 guidelines are utilized.

Therefore, the answer of which guidelines to use will depend on your provider and how he documents each element of the E/M service.