95 & 97 Guidelines

mmelcam

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I just went to an aapc seminar and here is how it was explained in the seminar. You can use both 95 and 97 guidelines when choosing an e&m code, just not on the same encounter..... meaning you can't use 95 guidelines on the history portion and 97 guidelines on the exam portion. If you choose 95 guidelines then you have to use it on all three sections (history, exam, medical decision making) when choosing your e&m code.
 

Jackie Stack

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You can use 95 or 97 guidelines when determining your level of service. Use whichever guidelines will benefit you the most for the visit you are looking at. Unless you have stated in your compliance plan that you will only use one or the other an auditor will use the one that benefits you the most when auditing your chart. You cannot use 95 for one part and 97 for another part of the same note.
 

codegirl0422

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I agree. It is important to make sure which one you are to use in your compliance plan.

You can use 95 or 97 guidelines when determining your level of service. Use whichever guidelines will benefit you the most for the visit you are looking at. Unless you have stated in your compliance plan that you will only use one or the other an auditor will use the one that benefits you the most when auditing your chart. You cannot use 95 for one part and 97 for another part of the same note.
 

CC5657

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Thanks! Another question, would you use 95 or 97 for a specialists office? I just heard that 95 should be used for a specialist & 97 for PCP's. Has anyone else heard that before???:confused:
 

Jackie Stack

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I work in family practice and I almost always use the 95 guidelines. We also do occupational medicine and many times find it more beneficial to use the 97 guidelines for these claims. I have found that specialists use the 97 guidelines more than the 95 because they are usually dealing with only one body area or organ system.
 

bigredcag

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i work for a multi specialty group. for our specialties(4 different ones) we use 97 guidlines and for Internal med and family practice we also use 97
we use 95 guidlines for occ.med and hospital visits
in our compliance plan it states "even though our forms are set up for 97 guidlines either 95 or 97 can be used for auditing/billing purposes.
this way when i audit i do what is best for the doctors/practice. and i am not restricted incase there is a need to use 95 guidlines.
 

sgochoco

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Difference between 95 & 97 guidelines

The best way to consider this question is to take apart the key components of documentation.

HISTORY: The rules for documenting the PAST MEDICAL, FAMILY and SOCIAL HISTORY and REVIEW OF SYSTEMS are identical for both the 1995 amnd 1997 E/M guidelines. The sole difference lies in the documentation of the HPI. The 1995 rules state that you must use the HPI elements to complete the HPI. A BRIEF HPI requires one to three of the HPI elements while an EXTENDED HPI requires at least four HPI elements. But, there is some language in the 1995 rules that also leaves the door open to documenting an EXTENDED HPI by commenting on four "associated co-morbidities." To be honest, it's not really clear if you can use the co-morbidities or if you have to use the HPI elements when completing the HPI using the 1995 rules. On the other hand, the 1997 E/M guidelines clearly state that you can qualify for an EXTENDED HPI by documenting four HPI elements OR by commenting on "the status of three chronic or inactive conditions."

PHYSICAL EXAM: The rules for documenting the exam are very different for the 1995 and 1997 E/M guidelines. The 1995 rules are pretty vague and rely on the documentation of various numbers of BODY AREAS and/or ORGAN SYSTEMS. It is very difficult to know for sure what exactly is required for each level of physical exam. On the other hand, the 1997 E/M guidelines state that the exam must be documented using specific BULLETS. The different levels of physical exam require a specific amount of bullets from the various organ systems. There are also several SPECIALTY EXAMS designed to contain relevant bullets from different specialties.

MEDICAL DECISION-MAKING: The rules for documenting the key component of medical decision-making are identical for both the 1995 and 1997 E/M guidelines.
 

GaPeach77

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Thanks! Another question, would you use 95 or 97 for a specialists office? I just heard that 95 should be used for a specialist & 97 for PCP's. Has anyone else heard that before???:confused:
I noticed while auditing that many specialist coders use 95. In my opinion, the ability to obtain a higher level is more user friendly, if I may, when using the 95 guidelines because of the focus to one body area.
 

colham478

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Just went to auditing seminar yesterday- seems to be that most auditors use 97 guidelines when auditing, but if you use 95 guidelines, they cannot say that you are wrong.

Also- be consistant!! Choose one or the other and stick with it- always. :d
 

MnTwins29

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Surprising

Many specialists use 95??? I always believed 97 guidelines were introduced because specialists felt 95 hurt them because they would do detailed exams in the area/system of their specialty instead of many different systems. The only specialty which I have audited has been OBGYN - and 97 will often be more beneficial to them.
 
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The other thing to do is to check with your local carrier. Some have an audit tool that will show that they are actually doing a bit of mixing of the 95 and 97 guidelines.

Never stick with just one guideline. If you are a specialists office, the 97's might help on some patients and the 95's might help on others. It's good to have both handy to check.

I have found with some of the specialty offices, after they do their exams, the 95's are actually more beneficial. Yet with others, because of the nature of the specialty, the 97's are more helpful.
 

rthames052006

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I agree with the statement " check with your carrier" some carriers may allow something that another one doesn't. I know that in my area, if auditing a CBC/KHP claim they use the 1997 DG and they have that info posted on their website as well. Just be careful.
 
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