Thomas, This is a question that most coders, billers and physicians often struggle with. Laureen offers the above video class that explains in details the process of coding E/M claims and medical records. There is also a site called E/M University that has articles in this subject. Here is one of them.... Hope this help.
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Both versions of the E/M guidelines may be downloaded free of charge by clicking
here for the 1995 rules and
here for the 1997 version.
Our View on the 1995 vs. the 1997 E/M Guidelines
There has been a lot of confusion about which set of guidelines is better for physicians. It's hard to say which set of rules is "better" because each version has advantages and disadvantages. Unfortunately, you are going to have to choose to use one or the other. It is NOT ACCEPTABLE to mix and match elements from both sets of rules within the same note. When everything is taken into consideration, we advise physicians to use the 1997 E/M guidelines. The best way for you to decide for yourself is to compare how the two versions treat the
key components of documentation.
History
It is clear that the 1997 E/M guidelines offer more flexibility when recording the
HPI portion of the key component of
History. Unlike the 1995 rules, the 1997 version allows physicans to document an extended HPI by commenting on the status of three or more chronic or inactive problems. On the other hand, the 1995 rules state that the physician must use the so-called
elements of HPI when completing the history. This rigid requirement can be somewhat stiffling because it is difficult to utilize the HPI elements when the patient has no somatic complaint to describe. The fact that
most encounters occur in the setting in which the patient has no such complaints makes using the 1995 guidelines an extremely dodgy proposition. Therefore, the 1997 rules are superior to the 1995 rules in regard to documenting the history.
Physical Exam
The physical exam rules are quite different for the 1995 and 1997 E/M guidelines. The
1995 exam rules may at first seem appealing to physicians because they are quite vague. You can basically document whatever you feel like documenting. This wiggle room may feel reassuring, but in the event of a documentation review, you can get yourself in trouble if your exam defintions don't coincide with the definitions used by the auditor. Conversely, the
1997 exam rules are quite specific and rely on the documentation of individual
bullets. Some physicians feel that the 1997 rules are overly rigid, but we disagree. The fact that the rules are so concrete makes following them quite easy. Either the bullets are there or they are not. Because the 1997 exam rules are somewhat arbitrary, we recommend that physicians use exam templates which contain the most clinically relevant bullets. Once you learn how to incorporate these bullets into your routine examination habits you can tell exactly what level of physical exam you have recorded by counting up the bullets. In the event of an audit, this makes your physical exam documentation "bullet proof."
Medical Decision-Making
The 1995 and 1997 E/M guidelines are identical when it comes to the key component of
Medical Decision-Making. That is to say, both versions are equally vague on the subject. At E/M University, we recommend using the much more precise
Medical Decision-Making Point System. This system was developed by CMS and distributed to all Medicare carriers to be used on a "voluntary" basis. All major academic centers and large institutions have incorporated this point system into their compliance programs. This scoring system is also being used by the CERT program. Perhaps the most compelling reason to use the Medical Decision-Making Point System is that this is how your cognitive labor will be judged in the event of a Medicare audit. So if you're not keeping score, somebody else may end up doing it for you.
