Pain Management Coding Alert

Question: I’ve heard that I can choose either the 1995 or the 1997 documentation guidelines for evaluation and management (E/M) services. Is that true? How do I know which version to pick?

Oregon Subscriber

Answer: Yes. For many payers, including Medicare, when coding, you may choose either the 1995or1997 documentation guidelines to calculate the level of service for a patient encounter. You can switch between the different versions from encounter-to-encounter.

Exception: In the past, you had to pick either the 1995 or 1997 guidelines and use your choice for the entire encounter. However, CMS changed its policy, so now for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended HPI, along with other elements from the 1995 guidelines to document the E/M service.

In other words:  For services your physician has performed since September 10, 2013, you may use the 1997 documentation guidelines for HPI that includes the status of three chronic conditions along with the exam criteria from the 1995 guidelines, or vice versa, using the 1995 HPI criteria with the 1997 exam guidelines.

Warning: Remember, this is a CMS policy and other payers may not follow this same exception. Be sure to check your payer’s guidelines.

As for choosing between the two sets of guidelines, you need to consider the content of your provider’s documents, the specific details captured in the record, the medical necessity of the information, and the specialty for which you code.