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1995 vs. 1997 Documentation Guidelines: Can a payer choose which?

  1. #1
    Question 1995 vs. 1997 Documentation Guidelines: Can a payer choose which?
    Medical Coding Books
    Good Morning!

    I need your help, fellow coders! One of our providers (I work for a health insurance company) submitted a code for an E&M visit and I reviewed it using the guidelines outlined in the E&M Handbook available on the CMS website. This apparently uses the 1997 Documentation Guidelines?

    The provider indicates they use the 1995 Guidelines and as a payer, we don't have the choice of which set we require from our contracted providers. The provider indicated they have the right to choose (which I can see that they do) but that the payer doesn't have that same right.

    This claim is for a non-Medicare patient. As a payer, can I review coding using the 1997 Documentation Guidelines and indicate a lower level of service is required, based on these?

    Thanks so much!

    Jodie, CPC

  2. #2
    I have never heard of any payer stating one set had to be used instead of the other. CMS policy is they will use both sets and whichever is most advantageous to the provider is the winner, and this is case by case.

    Since they are CMS guidelines you would think every payer using them would follow their lead and apply both, with the one being more advantageous used for the final level.

    Just my opinion, it will be interesting to see others experiences.

    Laura, CPC, CEMC

  3. #3
    Milwaukee WI
    Default BOTH are acceptable per CMS
    I agree with Laura. CMS clearly allows the provider to choose either 1995 or 1997 guidelines - and they can switch from note to note.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Cool 1995/1997 Guidelines
    Wow, this is something I have never considered. Please tell which payor made this statement.

    I audit my PCP's with 1995 and my specialists with 1997. It works out for me, but if a payor is going to challenge the usual and customary use of Guidelines, I'd like to know and see if any caveat in out provider contract addresses this.
    Last edited by bettze1947; 10-05-2009 at 08:15 AM. Reason: misspelling

  5. #5
    North Carolina
    Default're saying that as the carrier, your carrier only uses the 97 DG's? The AMA has made a statment regarding non-Medicare payers.

    Use of the 1995 and 1997 Documentation Guidelines by Non-Medicare Payers

    It is not the AMA's role to agree or disagree with payers' guidelines. Although many payers have documentation guidelines, it is important for providers to be aware of the specific guidelines for their third-party payers. For example, Medicare contractors may publish their guidelines on their Web sites, including "frequently asked questions" with the answers specific to their providers. One cannot assume, however, that all Medicare contractors have addressed the same issues, nor can a provider assume that the non-Medicare payers have all adopted the 1995 and 1997 Documentation Guidelines published by Medicare. Each third-party payer may have more-specific documentation guidelines than those published by CMS. However, any documentation guideline must properly use the definitions of CPT and be consistent with the CPT Evaluation and Management Services Guidelines.

    Providers do have the option to use 95/97 DG. If a payer uses 97 only and doesn't allow room for 95 comparison/use, I would be hesitant to re-sign the contract.

  6. #6
    I would question if the Payor ONLY ever uses the 97 guidelines, in which case, they might be able to be "correct" in this situation. However, if the Payor also goes back and forth, not only from claim to claim, but also to person to person in that company, then the argument would lie in, what does their contract state? If the contract does NOT state that they only audit claims based on the 97 guidelines, I guess they win, but not if that is not specifically stated.

    Could you imagine if every insurance company had the right to fight all of our submitted claims based on using the opposite guidelines that we use? It would be a mess! It doesn't seem ethical!
    Heidi Thompson, CPC

  7. Default Guidelines: Can a payer choose
    I would advise the payer to have their legal department look into this issue. There have been settlements made by Payers to the Providers due to litigation for inapprop. downcoding by using 97 guidelines instead of 95 guidleines.

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