Neurology & Pain Management Coding Alert

Mixing 1995 and 1997 guidelines is OK, but follow only one set per case.

Any time you select the best E/M code for a patient's office visit, you need to decide whether to follow the 1995 or 1997 E/M coding guidelines. Our experts help guide your choice with three tips that will keep every coder on track.

Background: When your physician examines a patient in the office, you'll choose an E/M code from 99201- 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components ...) for new patients or 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...) for established patients.

The level of physical examination is one of the key factors in helping you determine the correct E/M code. The physical exam key component splits into four categories - or levels - of complexity: problem-focused, expanded problem focused, detailed, and comprehensive.

Know the 1995 Versus 1997 Difference

The exam element is the most significant difference between the two sets of guidelines.

1997: The 1997 guidelines include specific physical exam elements that the provider must address in the documentation. If a physician addresses elements other than those specified in the guidelines, he won't necessarily receive credit for that element in the level of service. 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 exclude the element from being credited in the level of service.

1995: The 1995 guidelines are much less restrictive. They allow the physician to comment on any of the designated body areas and/or organ systems he examines. What the physician examines within the areas and systems and the wording he or she chooses to document are ultimately decided by the physician.

Switch Guidelines - Within Boundaries

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.

"Given that per Medicare, 'carriers and A/B Medicare Administrative Contractors are to continue reviews using both the 1995 and 1997 documentation guidelines (whichever is more advantageous to the physician),' physician practices are not restricted to using only one of the guidelines," says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver.

You can choose whichever set of guidelines is most advantageous for each encounter, adds Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with UPMC in Pittsburgh, Penn.

Caveat: The key is that you must use either 1995 or 1997 guidelines for a single encounter. Remember the guidelines apply to reporting the physical examination. The other two key components -- history and medical decision making -- remain the same no matter which physical examination guidelines you use.

Focus on Physician Documentation

So which set of guidelines should you use? The answer depends on your physician and his documentation.

"Typically the 1995 documentation guidelines are going to be more advantageous for most practices," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. "This is because they are more flexible and also because they reflect the way most physicians were taught to document. However, some physicians may have been taught or may have developed good documentation practices around the 1997 guidelines, and this may be advantageous to them."

Remember: Medical necessity must guide the exam -- and your physician may not need to examine every system trying to reach a higher E/M level.

"The physician should document everything he needed to check in order to appropriately assess the patient's condition but should not do 'extra' exam simply to meet a level of service," Bucknam says.

Bottom line: Choosing between the two guidelines can be difficult, but until a better system is in place, coders should use the set that is most beneficial for each visit　note.

Bonus: For a chart on how to easily choose an exam level based on your physician's documentation, email editor Leigh DeLozier (leighd@eliresearch.com).