Pediatric Coding Alert

Question: Would our general pediatric practice benefit more from using the 1995 or the 1997 E/M guidelines?

Illinois Subscriber

Answer: Technically, you can use the 1995 or the 1997 guidelines to support a given CPT code, such as 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history, detailed exam, and medical decision-making of moderate complexity). You can appeal a denial based on 1997 guidelines using 1995 criteria. The 1995 guidelines, however, are more physician-friendly without element bean-counting.

The 1995 E/M services' documentation guidelines allow more interpretation regarding a given examination type's performance and documentation requirements. For instance, CMS simply defines a detailed exam as "an extended examination of the affected body area(s) and other symptomatic or related organ system(s)." The CPT-adopted guidelines offer no further guidance on what comprises an extended exam, for example. This vagueness opens the door to differing opinions on a level's criteria and may cause disagreements among physicians and auditors.

The 1997 guidelines specify each exam types' countable components. For instance, a detailed general multi-system examination requires the physician to perform and document at least two bulleted elements from each of six areas/systems or at least 12 bulleted elements in two or more areas/systems.

The 1997 documentation guidelines' explicitness does not necessarily make it the better choice for your group. General pediatricians' patients do not often require detailed system exams, which better support system specialists, such as gastroenterologists or orthopedists.