95-97 guidelines used by doctors


Belleville, MI
Best answers
I know a doctor change change between using 1995 and 1997 guidelines for E/M.

The question is how often can they change between the two?

I am doing some auditing and have a doctor told me that he changes between 1995 and 1997 guidelines as he pleases. Sometimes from day to day or sometimes by patient. He never documents which guideline he is using.

This puzzles me. How can this be? Is there an industry standard that provides clear guidelines for this?

Confused coder :/
There is not an industry requirement for this. This is an internal protocol that must be set, if desired, by your management.

Providers may use whichever set of guidelines they wish. CMS auditors look at both sets when conducting audits as well.

If this is creating confusion for you then you should raise the issue to your management so they may decide if they want to set a limitation.
I agree with Nicole. Providers may choose to use whichever guidelines will allow them to code the highest per encounter; they can switch up as often as they feel necessary from patient to patient. I've even read that some MAC's will allow them to switch back and forth within the same encounter :eek:
Doesn't that get a bit confusion from an auditing stand point, do you just audit for 95 and 97 just in case? I mean is the Dr. going to be able to go back and say oh yes I meant to use the 97 guidelines for that patient?
You can switch?

I am very (pleasantly) surprised by the responses. I was taught that it didn't matter which set you chose, as long as you picked one or the other. However, once you picked, you were stuck with it, and you informed the auditor which set you were using. We recently went to an EHR that uses the '97 guidelines, but our Providers still use the '95 guidelines for hospital services, as they are more beneficial to us. From what I am reading here, this is okay to do? Does anyone know of any official references to this? I was unable to find any when we researched this once we started using our EHR.
There is no official guidance for this. This is one of those "gray" areas in our field and internal protocols should be set to guide your providers and support your coders/internal audit program (if one is in place).

As you audit more and more you will be able to easily identify which set of guidelines your provider has chosen as soon as you begin to read the documentation. Your either going to see a bunch of bullet point specific documentation such as in the 1997 guidelines or more simple body areas or organ systems under 1995 guidelines.

It is one or the other per encounter though. You can't mix the two sets in one progress note.