Wiki 1995 vs 1997 E/M guidelines mix and matching!

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Hello all,

I know that you can't mix and match the 1995 and 1997 guidelines for E/M coding. I need to proof this! Is there someone who can help me find the document from CMS?

Thank you,
Lilit
 
Thanks very much Laura,

Now I have another question. Doesn't the doctor's office have to determine which set of guideline they are going to use in their office? They can't use 1995 for half of today's patients and 1997 for the other half, can they?

Thank you,
Lilit
 
Our office made a decision to follow 1997 guidelines for all E/M services, but there is nothing that says you have to do that.

You can't mix and match the guidelines in a single note but you can use either 95 or 97 whenever you want. So the answer to your question is yes they can do that. I wouldn't personally advise it.

I have seen other posts where coders are educating based on 97 guidelines but will audit based on both and give them credit for whichever is higher.

I tend to shy away from the 95 guidelines because I have friends that do audits for the government and that is where they take back a lot of money.

Good luck,

Laura, CPC
 
Thanks Laura,

Being consistent is very impotant in the healthcare industry. I can't see why one will use the 1995 for half of the claims and 1997 for the other half.

Thanks very much Laura
 
Pediatrics

In our very large multi-specialty practice it's frequently more advantageous to use the 1995 guidelines for pediatrics ... unless you are in a specialty (like orthopaedics) where the 1997 single system exam is more to your benefit.

As for mixing the 1995 and 1997 guidelines in one note ... there are SOME carriers that allow this! Yes ... you read that right. Some carriers will allow you to use the 1997 status of 3 chronic conditions for the HPI and the 1995 guidelines for the rest (i.e. the exam). This was presented at a seminar I attended; our Medicare carrier isn't one of them so I didn't note which ones DID allow it, but there were some.

And certainly you can use 1995 on one note and 1997 on the next note without repercussion.

I will sometimes audit both ways on one note just to show the physician how it differs based on the guidelines used.

F Tessa Bartels, CPC, CEMC
 
helpful link to NHIC document

Thanks to Laura for that helpful link to the NHIC document, which spells out the fact that you can use 1995 or 1997 on any given note. I agree that it is a good idea to be consistent within one office, but on the other hand, in my job, the provider codes the encounter and I review it. My goal is to agree with the provider, as long as I am confident I can justify the level based on 1995 or 1997. And the NHIC document backs me up, because it says that the auditors are supposed to use whichever set of rules favors the provider.

One of the tricky aspects of 1995 exam rules is what is an "extended exam of affected system". I am not sure what the minimum should be, but there are times when it is clear that the exam was extended and so I feel I can justify "detailed" exam. Strangely, the comprehensive exam in 1995 is less subjective - 8 or more systems examined.

Another thing I like about 1995 rules is that an instructor once gave me an ingenious 3.5" by 8.5" card, which acts as a complete set of rules for all office visits, consults and inpatient visits, including coding by time. She gave it freely and claimed no copyright on it. One of these days I will recreate it so I can give it out electronically.

- Paul C.
 
Paul,
The same NHIC attachment outlines that they consider the 1995 exam to be as follows:
Problem Focused - 1 Organ system/Body area
Expanded Problem Focused - 2 to 4 Organ systems/Body areas
Detailed - 5 to 7 Organ systems/Body areas
Comprehensive - 8 or more Organ systems

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That makes it less subjective than the CPT definition. I hope that helps. Note that for a Comprehensive exam you can only use Organ systems - no body areas. For the lower 3 levels (PF, EPF, Det) you can count organ systems and body areas.
 
detailed per 1995

Hi Mike,
Thanks for that. I don't remember a specific number of BA/OS being mentioned in the 1995guidelines themselves. I still think the "extended exam of the affected BA/OS" is important, so now I will make sure I have that criterion met, plus at least 5 BA/OS. I think those criteria are met more often than 12 bullets - and easier to count. With 1997 rules, it is not clear that each item mentioned by a provider under a given system counts as a bullet.

I used to think it was better to use 1997, because the criteria seemed more objective, but I am starting to think 1995 is better, because the criteria seem more driven by addressing the chief complaint. You could have 12 bullet points to get a "detailed" exam by 1997 rules, but how many of them are really related to the complaint? Maybe it is better to do an "extended" exam of the affected area or system plus a few other areas/systems.

Thanks,
Paul
 
As an auditor, it depends on the specialty of the physician you are auditing. 9 times out of 10 I use the '95 exam guidelines. Primary care, Pediatricians, Senior care, Family care, hospitalists, emergency department, etc etc.... mostly I rely on '95 and just count the organ systems and body areas.

I do use 97 when I'm auditing psych notes, and occasionally for neurology. Regarding your point about "how many of them are really related to the complaint?" as an auditor who is not a trained clinician I can't make that call, I just count it. If you start to decide to count things or not based on whether you feel it is clinically relevant - just beware.... you may find yourself swimming in waters above your head if you get into an argument with the doctor about why his exam was not relevant. Just a tip.
 
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