E/M Documentation Guidelines:
Eye Experts Say Use 1997, Not 1995 Version
Published on Fri Jan 01, 1999
The Health Care Financing Administration (HCFA) says you can use either the 1995 or the 1997 documentation guidelines for Evaluation and Management (E/M) services, but you must use one or the other, and you must use it consistently. The 1997 guidelines were originally scheduled for publication in CPT 1999, but instead the 1995 version still appears. However, this is only while HCFA is working on a revised set of new guidelines, expected out in late 1999 or early 2000.
Simpler Documentation
Two ophthalmological coding experts were consulted for this article, both of whom recommend the use of the 1997 guidelines. A lot of ophthalmologists would rather use the 1995 version, because they appear to require less documentation, says Ann Rose, president of Rose and Associates, a Duncanville, TX-based consulting firm specializing in Medicare reimbursement and compliance in ophthalmology. But for ophthalmology, the 1995 guidelines are not simpler. Using the 1995 edition leaves the determination of the level of service to the discretion of the individual carriers medical reviewer, says Rose. While the 1997 edition defines exactly what constitutes a certain level of service for the examination component of an E/M service.
The 1995 E/M codes were written for the general doctor, not the specialist, she explains. Until 1992, Rose adds, ophthalmologists and optometrists had their own set of codes in addition to the medical visit 90 series of codes. All other physicians used the 90 series. The 99 series (as in 99212) of E/M codes replaced the 90 series in 1992, and were developed for use by all specialties. The single organ system documentation guidelines were developed for 10 specialties, including ophthalmology, in May of 1997.
The documentation guidelines for each level are:
Problem-focused exam (99201 or 99212) you need to have one to five elements;
Expanded problem focused exam (99202 or 99213), you need at least six elements;
Detailed exam (99203 or 99214), you need at least nine elements;
Comprehensive exam (99204, 99205, or 99215) you need to perform all of the above elements, and also provide a brief assessment of the patients mental status, either by orientation to time, place, and person; or by mood and affect (e.g., depression, anxiety, agitation).
(Reminder: The examination alone doesnt determine the level of service; you must also meet certain criteria for history and medical decision-making. For a comprehensive level of E/M service, the history must contain the chief complaint, the history of the present illness, a complete review of systems, and a complete past, family, and social history (PFSH). Under the 1997 guidelines, a brief history of the present illness (one to three elements of the illness) would only qualify for a level 2 or 3 E/M service; a level 4 or 5 [...]
