General Surgery Coding Alert

Question: Which guidelines for E/M documentation (1995 or 1997) should we use when reviewing chart dictation?


West Virginia Subscriber

Answer: You may choose either the 1995 or the 1997 documentation guidelines for E/M services. Medicare has stated that it will check E/M coding against both documentation guidelines before deciding whether you have met the recorded level of service. Physicians are not constrained from switching back and forth to suit the situation or their mood.
 
In 1995, CPT developed E/M guidelines to define the intensity of medical service delivered while maintaining some flexibility to accommodate the natural variations found in medical practice. The guidelines instructed physicians to conduct a complete single-system or a complete multisystem exam, but gave little guidance regarding what constituted a complete exam. When a surgeon chose to do a comprehensive musculoskeletal examination, for instance, there was no tool to measure when he or she reached the comprehensive level.
 
With input from HCFA (now CMS), CPT later created the 1997 E/M guidelines, which replaced the ambiguity of the 1995 guidelines by specifying a list of bullet items in the exam that the physician must perform to justify a given level of service. The 1997 rules required the physician to document everything and tried to make the examination criteria for one discipline comparable to other disciplines, which also made it easier for auditors to assess the level of service provided.
 
Although the 1997 guidelines are more exacting and perhaps more challenging to work with than the 1995 guidelines, the precision of the later guidelines (as well as the availability, for the first time, of a single specialty examination) allows for better documentation and audit protection. But the 1997 guidelines may be inappropriate for pediatric services and make billing higher-level E/Ms virtually impossible for specialties like otorhinolaryngology and ophthalmology where the scope of practice is limited to specific parts of the body.