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Thread: 95' E/M Guidelines "updated" ?????

  1. #1

    Cool 95' E/M Guidelines "updated" ?????

    AAPC: Back to School
    I had an auditor in my office and we were discussing some of the coding issues. One thing surprised me. She said that the 95 E/M guidelines had been "updated" and due to this, 5 body systems was a "detailed" exam now. To my knowledge, the 95 guidelines have not been "amended" or "updated" since 95. Does anyone know what she is referring to ?

    According to her the affected area is PF

    2-4 systems is EPF

    5-7 systems is DETAILED

    8+ systems is Comp

    Has anyone heard of this?

  2. #2


    Hi I have never seen any "updates” to “95” guidelines although I was told obtain that you need 5-7 exam elements for a detail exam.
    Ingenix has an E&M book Understanding E/M Coding and in this book it states that it is a safe harbor to have 5-7 exam for detail in addition the 3M encoder software does the same with 5-7 exam elements for detailed exam
    Robin Ingalls-Fitzgerald CCS, CPC, FCS, CEMC, CEDC

  3. #3


    I'm pretty sure this is an interpretation.. not an update.

    5-7 may be detailed but what happens if you have 2 organ systems examined and you go into great depth about one? Is that not considered detailed? Well actually it very well may be ...

    It all comes down to the power of your argument and the clinical judgement of the physician - ask them what they believe to be a detailed exam. Take that interpretation (making sure it's reasonable) and put it in your compliance plan and follow it!

  4. #4
    Join Date
    Apr 2007
    North Carolina


    I agree...I think it's a matter of the carriers interpretation of what constitutes a detailed exam. Some carriers require 5-7 organ systems for a detailed 95 exam...others may allow 2-7.

    My carrier's view....

    Question: What’s the difference between an expanded problem-focused exam and a detailed exam?

    Answer: Per the 1995 E&M guidelines, the least level of exam involves a limited examination of the affected body area or organ system. The highest level exam, i.e. a comprehensive exam, is defined as a general multi-system examination or complete examination of a single organ system. Furthermore, a general multi-system examination is described as including findings about 8 or more of the 12 organ systems. Therefore, both an expanded problem focused exam and detailed exam may include assessment of 2-7 organ systems. As a detailed exam is expected to involve a greater work effort than an expanded problem focused exam, it is generally perceived that a detailed exam assesses more systems than an expanded problem focused exam; and, subsequently, the question is asked where the line of demarcation between the two exam types is. Many inquirers have asked us “does an exam become detailed at the 5th system addressed…or is it at the 6th system? CMS doesn’t specify. In fact, CMS describes the exams as follows: “ Expanded Problem Focused” is a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) whereas “Detailed” is an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

    As a carrier we are reluctant to set what could be an arbitrary parameter. In the E&M reviews we do, we determine the level of exam based on this range/number of systems but also on the amount of exam effort that was medically reasonable and necessary for the provider to diagnose and treat the patient. Providers are cautioned not to perform/document exam elements greater than the patient’s need in order to claim a greater level of work and justify billing a higher level of service than the patient required.

  5. #5
    Join Date
    Apr 2007
    Kachina Coders


    I was just at our companies round table of coders meeting and was told the same thing that there has been an update to the 95 guidelines. i am a firm believer that when someone makes such a statement as that, they need to back it up with written documentation from the source. To many times i hear that coding is someones interpetation of the guideslines. I disagree with that, as much of it is black and white, with a few grey areas.
    Mesa, AZ

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