Neurosurgery Coding Alert

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

West Virginia Subscriber

Answer: Essentially, you can use either the 1995 or 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 prior guidelines by specifying a list of "bullet" items in the examination component that the physician must perform to justify a given level of service. The 1997 guidelines required the physician to document very specific items and tried to make the examination criteria for one discipline equivalent to other disciplines, which also made it easier for auditors to assess the service level 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 neurological or musculoskeletal single-system exam) is more appropriate for specialists and allows for better documentation and audit protection. But the 1997 guidelines may be inappropriate for pediatric services and makes billing higher-level E/Ms virtually impossible for specialties like otolaryngology and ophthalmology where the scope of practice is limited to specific parts of the body.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.