1995 vs. 1997 guidelines: Choose one per claim, but feel free to use either one for different claims. 1. How Do I Determine the Physical Examination Level? There are two sets of 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 urologist completed during an E/M service: problem-focused, expanded problem focused, detailed, and comprehensive. The level of exam is a 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 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. 2. What's the Difference Between 1995 and 1997 Guidelines? The exam element is the most significant difference between the two sets of guidelines. 1997: 1995: 3. Which Guidelines Should I Use? 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. "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, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with UPMC in Pittsburgh, Penn. Essential: 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, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. So which should you use? That depends on your urologist 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: Bottom line: 4. Can My Urologist Use a Template for Exam Documentation? Having your urologist use a paper template or one within your EMR can be helpful to ensure he captures every piece of his exam, but use caution. "Templates are a good way to ensure capturing of all elements of the exam, but physician training can help with this also," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. "If you do use a template it really is a good idea to tailor it to the specialty." "Templates can be useful as long as they are not abused," Bucknam agrees. "The appropriate exam is the exam that the physician thought was needed in order to appropriately assess the patient's presenting problem. Putting in a bunch of other useless stuff is inappropriate." Warning: