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95? Or 97? Or Both?

  1. #1
    Default 95? Or 97? Or Both?
    Medical Coding Books
    I could swear that I'd read that an office can use EITHER the '95 guidelines OR the '97 guidelines, but they should pick one and stick with it. But now I'm being told you can switch back and forth from claim to claim depending on which is better for reimbursement. Someone please clarify. Please and thanks!!!!!

  2. #2
    Overland Park, KS
    You can not switch back and forth!!!! You are correct that the providers may use either the 95 or the 97 guidelines, but whatever one that they choose, they must stick with. They can not switch back and forth.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  3. #3
    Again if I remember correctly, the OIG has a ruling on this. Can anyone help lead me to the "black and white" judgement on this?

  4. #4
    Greeley, Colorado
    Hmmm - I always thought that unless there was a compliance guideline in place for the clinic, either or could be used. I have specialists as well as FP and IM and quite often use 95 vs 97 depending on the provider. I would like to see something in black and white as well. At workshops it has been suggested that the doctors choose 95 or 97 and put that in the compliance plan, but I have never heard that I could not use 95 for one doctor and 97 for another...
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Milwaukee WI
    Default I believe you can use both, but ...
    We are a very large practice (over 200 providers), with both specialists and PMDs. We use both guidelines, depending on which is more advantageous to the specific case. But our compliance plan states that we will do that.

    Of course, you cannot use both guidelines on the same document. But you can switch from document to document, if your compliance plan allows that.

    However, if your compliance program states "we will use '95 guidelines" then that is what you need to stick to.

    F Tessa Bartels, CPC, CPC-E/M

  6. #6
    North Carolina
    Lisa and F Tessa Bartels are correct. Depending on your physician or physician's specialty, you can select the 95 or 97 guidelines. You can't, however, mix and match elements from both sets of rules within the same note. I'm not sure if this is what you're looking for...if not, disregard.

    24 "For additional information on proper documentation, physician practices should also reference the Documentation Guidelines for Evaluation and Management Services, published by HCFA. Currently, physicians may document based on the 1995 or 1997 E&M Guidelines, whichever is most advantageous to the physician."

    (The above excerpt is found in small print in this article)
    Rebecca CPC, CPMA, CEMC

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