1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities. 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions.
What is the difference between the 1995 and 1997 guidelines?
When comparing the 1995 to the 1997 guidelines, it is apparent that the biggest change was in history and examination, while medical decision making remained the same. So, what is different about the guidelines? The following shows how the 1997 guidelines changed when compared to the 1995 guidelines.
When to use 1997 documentation Guidelines for an extended history?
...However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.
Can a provider choose which version of documentation Guidelines to use?
For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter.
What are the differences between the 1995 and 1997 HPI guidelines?
You may follow either the 1995 or 1997 guidelines in determining the appropriate level of service. In comparing the guidelines, changes to 1997 are as follows: HISTORY – In 1997, an extended HPI includes the status of at least 3 chronic or inactive conditions. This is the only change.
What areas are different between 1995 and 97 EM coding guidelines?
1995 versus 1997 E/M Guidelines Two major differences exist between the 1995 and 1997 E/M guidelines: HPI and the exam element. The following criteria are the same for the 1995 and 1997 E/M guidelines, including: The Review of Systems; Past, Family and Social History; and Medical Decision Making.
Can a provider use both 1995 and 1997 documentation guidelines?
The most substantial differences in the 1995 and 1997 versions of the documentation guidelines occur in the examination documentation section. For billing Medicare, you may use either version of the documentation guidelines for a patient encounter, not a combination of the two.
What are the elements of the history of present illness according to the 1995 and 1997 documentation guidelines?
HISTORY OF PRESENT ILLNESS (HPI) It includes the following elements: location; quality; severity; duration; timing; context; modifying factors; and associated signs and symptoms.
What are 97 guidelines?
The 1997 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient's visit: General multi-system examination and Single organ examination. A general multi-system examination involves the examination of one or more organ systems or body areas.
What are the 3 key components for non office visit E&M using the 1995 1997 guidelines )? 3 points list them in the order they appear on the audit tool?
These components are: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services.
How many body systems are recognized for review of systems according to the 1995 and 1997 documentation guidelines?
10 body areasThe 1995 guidelines differentiate 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and ...
How many Ros elements are present?
There are three levels of ROS recognized by the E/M guidelines: Problem Pertinent ROS : Requires review of ONE system related to current problem(s) Extended ROS: Requires review of TWO to NINE systems. Complete ROS: Requires review of at least 10 systems.
What are the three major components of E M documentation?
Many E/M codes, such as those for inpatient care and home visits, include a combination of patient history, examination, and medical decision making (MDM). These factors — history, exam, and MDM (HEM) — are known as the three key components of E/M level selection.
What is the difference between problem focused and expanded problem focused?
Problem-Focused – A limited examination of the affected body area or organ system. Expanded Problem-Focused –A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
How many HPI elements are there?
Two of the eight HPI elements are context and modifying factors. The other elements of the HPI are: Location.
How many types of examination are there in the E&M coding system?
There are two types of examinations that can be used to determine the level of exam; 1995 and 1997 Evaluation and Management (E/M) Documentation Guidelines. Providers may use whichever exam is most beneficial to them.
How many review of systems does 99214 have?
twoA 99214 requires a review of only two. For a 99204, the past, family and social history must cover all three areas. A 99214 requires only one area. For a 99204, the physical exam must cover at least 18 bullets from at least nine systems or body areas.
What is the 1997 E/M?
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.
Why is the HPI requirement stiffling?
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.
Is the 1995 E/M the same as 1997?
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 .
Is the 1997 exam rigid?
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.
Weigh the Elements
HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
Choose Wisely
The two types of HPIs are brief and extended. Whereas a brief HPI includes documentation of one to three HPI elements, an extended HPI:
What is medically implausible documentation?
Medically implausible documentation. Auditing Tip: Auditors are instructed to audit under both sets of guidelines and apply the guideline that benefits the physician. If you state in your compliance plan that you are using one set of guidelines, you will be held to that and will lose the flexibility to use the other.
What is the difference between 1995 and 1997 E/M?
There aren’t a lot of differences between the 1995 and 1997 E/M guidelines, but there are pros and cons to using either set. The 1995 guidelines came out first, tend to be pretty broad, and often there are a lot of gray areas requiring you to make judgment calls. The 1997 guidelines are more specific and for some specialties, ...
How many elements of HPI should be described in 1997?
If using the 1997 documentation guidelines, the provider should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions. The provider cannot simply state that the patient has the condition, but he must also give the status. For example:
Why is the history of present illness important?
The History of Present Illness is important because it supports the medical necessity of the visit. The HPI may be brief or extended. A brief HPI documents 1-3 of the following elements: An extended HPI documents four or more elements of the present HPI or associated comorbidities, under the 1995 E/M guidelines.
What is the number of possible diagnoses and/or the number of management options that must be considered?
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.
What is the key or controlling factor to qualify for a particular level of E/M services?
In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.
What is the amount and complexity of data to be reviewed?
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.
What is the number of possible diagnoses and/or the number of management options that must be considered?
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.
What page is the multi system exam?
General multi-system examinations are described in detail beginning on page 13. To qualify for a given level of multi-system examination, the following content and documentation requirements should be met: