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Thread: 95 & 97 Guidelines

  1. #11


    AAPC: Back to School
    Quote Originally Posted by KAM5657 View Post
    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???
    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.

  2. #12
    Join Date
    Apr 2007


    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

  3. #13
    Join Date
    Apr 2007
    Carmel, New York

    Default 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.


    2016 Secretary
    Ellenville, NY Local Chapter

  4. #14
    Join Date
    Apr 2007
    Central Pittsburgh


    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.

  5. #15
    Join Date
    Apr 2007
    York, Pa


    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.
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

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