Wiki 1995 vs 1997 guidelines

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Good morning,

First let me leave the CMS E/M guidelines right here.

Second, the main two differences you will find once you read through the above guidelines are the HPI and Examination components.


From the guidelines about HPI (extended):

"*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"


For the Exam portion, it gets a little more complicated.

1995 guidelines do not give you an exact number directly, but rather the following is provided:

"Problem Focused -- a limited examination of the affected body area or organ system.
Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
Comprehensive -- a general multi-system examination or complete examination of a single organ system. "

Some payers/auditors have tried to quantify these terms, however this is what the guidelines state. You may want to check with your payers for additional information.

1997 makes the distinction a little easier:

"Problem Focused Examination – should include performance and documentation of one to five elements identified by a bullet (•) in one or
more organ system(s) or body area(s).
Expanded Problem Focused Examination – should include performance and documentation of at least six elements identified by a bullet (•) in one
or more organ system(s) or body area(s).
Detailed Examination – should include at least six organ systems or body areas. For each system/area selected, performance and documentation of
at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems
or body areas.
Comprehensive Examination – should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.
[For specialty exams] - should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected. "

Our clinic uses the 1997 guidelines since we are a multi-specialty group, which tends to favor 1997 guidelines. However the guidelines further explain that you can mix and match between the 1995/1997 guidelines:
"For reporting services furnished on and after September 10, 2013, to Medicare, you may use the 1997 documentation guidelines for an extended HPI along with other elements from the 1995 documentation guidelines to document an E/M service.".
Note that not all payers might follow this rule, again check with your payer on this one.


The Medical Decision Making remains the same regardless of which guidelines you choose. Documentation of Time is also an option, which would not change depending on your choice of guidelines either, as long as documentation shows "Greater than 50%...." along with a brief statement of what was counseled.

Hope this is helpful, if not feel free to probe further with questions.
 
Pathos said:
Good morning,

First let me leave the CMS E/M guidelines right here.

Second, the main two differences you will find once you read through the above guidelines are the HPI and Examination components.


From the guidelines about HPI (extended):

"*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"


For the Exam portion, it gets a little more complicated.

1995 guidelines do not give you an exact number directly, but rather the following is provided:

"Problem Focused -- a limited examination of the affected body area or organ system.
Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
Comprehensive -- a general multi-system examination or complete examination of a single organ system. "

Some payers/auditors have tried to quantify these terms, however this is what the guidelines state. You may want to check with your payers for additional information.

1997 makes the distinction a little easier:

"Problem Focused Examination – should include performance and documentation of one to five elements identified by a bullet (•) in one or
more organ system(s) or body area(s).
Expanded Problem Focused Examination – should include performance and documentation of at least six elements identified by a bullet (•) in one
or more organ system(s) or body area(s).
Detailed Examination – should include at least six organ systems or body areas. For each system/area selected, performance and documentation of
at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems
or body areas.
Comprehensive Examination – should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.
[For specialty exams] - should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected. "

Our clinic uses the 1997 guidelines since we are a multi-specialty group, which tends to favor 1997 guidelines. However the guidelines further explain that you can mix and match between the 1995/1997 guidelines:
"For reporting services furnished on and after September 10, 2013, to Medicare, you may use the 1997 documentation guidelines for an extended HPI along with other elements from the 1995 documentation guidelines to document an E/M service.".
Note that not all payers might follow this rule, again check with your payer on this one.


The Medical Decision Making remains the same regardless of which guidelines you choose. Documentation of Time is also an option, which would not change depending on your choice of guidelines either, as long as documentation shows "Greater than 50%...." along with a brief statement of what was counseled.

Hope this is helpful, if not feel free to probe further with questions.
Click to expand...

Thanks for your valuable time and knowledge sharing.
 
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