Oncology & Hematology Coding Alert

1995 vs. 1997 guidelines: Limit yourself to one set per claim.

Whether you need a quick link to 1995 and 1997 E/M guidelines or a refresher on how the guidelines differ for the exam component, the answers to three FAQs can help keep your physical exam selection on track.

1. Where Do I Find Exam Level Guidelines?

There are two sets of guidelines you should be familiar with before trying to determine the level of the physicalexamination key component for your E/M coding: 1995 and 1997 guidelines. You may download them from www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

Either set of guidelines can help you determine which of the following four levels of examinations your oncologist completed during an E/M service: problem-focused, expanded problem-focused, detailed, and comprehensive.

Understanding the guidelines is important because the level of exam can be a factor in many E/M codes, such as outpatient/office codes 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.

2. How Do 1995 and 1997 Guidelines Differ?

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. If a physician addresses elements other than those specified in the guidelines, the physician will not 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 accidentally exclude the element from being credited in the level of service.

1995: The 1995 guidelines are much less restrictive. They allow the physician to make any comment in any of the designated body areas and/or organ systems he examines. What the physician examines within the areas and systems and the wording she chooses to document are ultimately decided by the physician. (Check back next month for a Clip and Save tool to see how to count the elements for each set of guidelines and choose your code level.)

3. Which Guidelines Should I Use?

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'll find this statement from Medicare at the same website as above, www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.)

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

Essential: The key is that you have to use either the 1995 or the 1997 guidelines for a single encounter. For example, you may not use the 1997 guidelines for the history element and then 1995 guidelines to score the exam.

Caution: Before deciding which guidelines to use, "practices should be aware of any special requirements that are part of their contracts with their insurers," warns Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPCP, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

So which should you use? "Typically the 1995 documentation guidelines are going to be more advantageous for most practices," Bucknam explains. "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." Some coders also have found that the 1997 exam is more advantageous to their particular practice's specialty, such as dermatology and neurology, due to the specialized nature of a comprehensive examination.

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