Radiology Coding Alert

When you begin coding E/M services, you will probably confront both the "1995 Documentation Guidelines" and the "1997 Documentation Guidelines." Which set should you rely on? CMS developed 1997 E/M guidelines to replace the 1995 version, but these were universally viewed as overly complex and requiring more documentation than clinically necessary.

The '95 DGs allow physicians and coders to count individual elements reviewed during an E/M visit. The sum of these elements guides coders to choosing the correct level of E/M service to report. The '97 guidelines, however, included a complex system of shaded boxes and bulleted items that baffled physicians and coders alike. As a result, the '95 DGs are universally accepted as the standard for E/M coding.

After the fallout from the '97 guidelines, CMS began working on additional modifications. New guidelines were drafted and circulated in 2000. Work on these guidelines was suspended a year ago because physicians continued to express concern that the modifications hindered patient care. CMS has not announced when revised draft DGs will be available. A comparison of the E/M documentation guidelines is located at www.hcfa.gov/medlearn/emdoc.htm.