CMS Provides Welcome E/M Flexibility

by John Verhovshek, MA, CPC

Effective since Sept. 10, 2013 CMS allows an extended history of present illness (HPI), as defined by the 1997 Evaluation and Management Documentation Guidelines, with the other elements of the 1995 guidelines. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for either the ‘97 or ‘95 guidelines.

CMS announced the change as a “Question and Answer” on its website:

1. 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?
2. 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.

CMS has also updated its Evaluation and Management Services Guide to reflect the new policy.

Coders should be aware of this change, and should measure E/M services against the revised guidelines. Those physicians who manage patients with multiple chronic conditions, especially, may find that the new rules allow their coding and billing to better reflect the documented level of service provided, thereby legitimately boosting E/M levels and reimbursement levels. If providers are already documenting their services well, they won’t have to change their process to realize an advantage from these revised E/M guidelines.

• About
• Latest Posts

John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

Latest posts by John Verhovshek (see all)

• Excision of Benign or Malignant Skin Lesion - April 21, 2019
• 49905: Open or Closed? - April 21, 2019
• Pain Management and the Global Period - April 21, 2019