Pulmonology Coding Alert

Hint: You can vary between the two E/M guidelines for each encounter.

If choosing between the 1995 and 1997 E/M guidelines has kept you on your toes while reporting an E/M encounter, the guidance that follows will help you choose the right set of guidelines for every session depending on your practitioners documentation and level of physical examination.

Focus on the 1995 vs. 1997 Differences

There are two sets of documentation guidelines you should be familiar with before trying to determine the level of the physical examination key component for your E/M coding: 1995 and 1997 guidelines.

Both sets of guidelines help you determine which of the following four levels of examinations your provider completed during an E/M service: problem-focused, expanded problem focused, detailed, and comprehensive. The level of exam is a required factor in determining which code you can report: 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 a potential factor in 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. 

Note: All three key components (hx, exam, MDM) are considered when selecting new patient visits; two key components (MDM plus either hx or exam) are considered when selecting established patient visits.

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, both for a general multi-system exam and for single organ system examinations. If a physician addresses elements other than those specified in the guidelines, the physician will not necessarily receive credit for those elements 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 inadvertently exclude the element from being credited in the level of service.

1995: The 1995 guidelines are much more general and, therefore, much less restrictive in a way. They allow the physician to make any comment in any of the organ systems he examines. What the physician examines within the systems and the wording he or she chooses to document are ultimately decided by the physician. See the chart to see how to count the elements for each set of guidelines and choose your code level. 

Note: Documentation is credited against “organ systems” when selecting a comprehensive exam.  Most contractors will no longer give credit to “body areas” because of the ease in which a provider can achieve comprehensive credit when documenting according to “body areas” rather than “organ systems.”

Choose the Best Guidelines Per Encounter

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 from one service to the next. “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 can choose whichever set of guidelines is most advantageous for each encounter, says Suzan Berman, MPM, CPC, CEMC, CEDC, manager of physician compliance auditing for West Penn Allegheny Health Systems, Pittsburgh, Penn. For more details, check this MAC website on http://www.cahabagba.com/part-b/education/evaluation-and-management-services-information-center/

Essential: The key, however, is that you have to use either 1995 or 1997 exam guidelines for a single encounter. Remember, the guidelines differ primarily in the reporting of the physical examination, but there is a minor difference in the History of Present Illness (HPI) as well.  CMS has just updated their guidance on the use of 1995 vs 1997 Documentation Guidelines for the HPI (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/EM-FAQ-1995-1997.pdf):

Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?

A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.  

Caution: “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, CPC-P, CPC-I, CCC, COBGC, internal audit manager at CHAN Healthcare in Vancouver, Wash.

So which guidelines should you use? That depends on your provider and how he documents. “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.”

Example:  A 40-year-old female presents to the office for re-evaluation of asthma.  Since her previous office visit, her condition has worsened with the present therapy of Symbicort. Patient c/o chest tightness; no reported fevers, but has had chills and nausea. The encounter includes the following details:

Vital Signs: BP 126/80 | Pulse 89 | Ht 5’ 4” (1.626 m) | Wt 145 lb (65.772 kg) | SpO2 96%

HEENT: Eyes: PERRLA, anicteric; Oropharynx: benign

Neck: normal

CV: normal sinus rhythm, peripheral pulses normal

Respiratory: lungs clear bilaterally, no wheezing, rales, normal symmetric air entry

GI: normal bowel sounds, abdomen is soft without significant tenderness or masses

Skin: Warm and dry; no hyperpigmentation, vitiligo, or suspicious lesions

Musculoskeletal: No clubbing or peripheral edema.

A/P: Mild persistent asthma remains worsened. Patient has dizziness occurs more frequently with exercise.  Given the above symptoms, I would recommend Otorhinolaryngology evaluation and exercise test. 

The above example would be reviewed against both sets of guidelines. 

• 1995: PE: comprehensive exam (1 comment in 8 systems: constitutional, eyes, ENMT, CV, Respiratory, GI, musculoskeletal, and integumentary).  
• 1997: Expanded-problem focused exam (10 bulleted items).

Bottom line: Choosing between the two guidelines can be difficult, but until a better system is in place, coders should use the set that is most beneficial for each visit note. “Some specialties will benefit from the use of 1995 rules; others will benefit from the use of the 1997, so make sure to look closely when making these changes in your practice,” says Becky Boone, CPC, CUC, with The Coding Network and the University of Missouri Internal Medicine Department in Columbia.