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95 & 97 Guidelines

  1. #1
    Question 95 & 97 Guidelines
    Medical Coding Books
    Can you use both 95 & 97 guidelines when determining a E/M level?

  2. #2
    Smile
    I was taught that you can only use one or the other not both....
    Hope this is true....

  3. #3
    Location
    St. Louis, Missouri
    Posts
    262
    Default
    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.

    Melissa Blow, CPC

  4. #4
    Default
    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.

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

    Quote Originally Posted by Jacqueline Stack View Post
    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.

  6. #6
    Default
    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???

  7. #7
    Default
    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.

  8. #8
    Default
    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.

  9. Question 95 97 guidelines
    what exactly are 95 & 97 hospital guidelines?

  10. #10
    Default 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.

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