When To Use Both ’95 and ’97 Documentation Guidelines
When billing Medicare, a provider may use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management (E/M) CPT or HCPCS Level II code. For services performed on or after September 10, 2013, however, physicians may use the 1997 documentation guidelines for an extended history of present illness (HPI) along with other elements from the 1995 guidelines to document an evaluation and management service.
Weigh the Elements
HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
HPI elements are:
- Location (example: left leg)
- Quality (example: aching, burning, radiating pain);
- Severity (example: 10 on a scale of 1 to 10)
- Duration (example: started 3 days ago)
- Timing (example: constant or comes and goes)
- Context (example: lifted large object at work)
- Modifying factors (example: better when heat is applied)
- Associated signs and symptoms (example: numbness in toes)
The two types of HPIs are brief and extended. Whereas a brief HPI includes documentation of one to three HPI elements, an extended HPI:
- 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities.
- 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions.
Centers for Medicare & Medicaid Services, FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services