’95 or ’97 Guidelines? This Evaluation and Management Coding Training Simplifies It!

In case you can't prove medical necessity, you do not get reimbursed appropriately. However document services accurately and you'll right away boost your payments. Learn which documentation guideline is more beneficial to your provider in with this expert guidance provided by our healthcare training expert. 

Scenario: As per a physician’s note, a patient named Sarah came in with extreme tenderness over her thumb with a history of broken glass exposure. The note goes into talking about how the patient had been seen by this physician before. And then it goes into the components of her thumb, the exam in regard to her left thumb has a callous measuring 4x5mm. She's right handed. Because of the findings in the exam, the physician took an x-ray. By the read, there is indeed a piece of glass. The physician discussed the options available to her and asks her to come back.


Remember, the physician in the note that we originally started with said on exam, her left thumb has a callous measuring 4x5mm. There is some tenderness and fullness in the mid-pulp. She has full range of motion of her left hand. She is right-handed. This is where the 1995 guidelines and the 1997 guidelines are very clear.

The 1995 evaluation and management documentation guidelines illustrate that this would be an expanded problem focused exam. The 1997 guidelines show that this is only a problem focused exam. So let's take that apart a little bit. If you're one of the offices that only uses the ‘97 guidelines exclusively, you'll see essentially why this is a lower exam than using the ‘95s.

In the ‘95s, the callous goes under skin. And the full range of motion can go under musculoskeletal. In the 1997 guidelines, we've got two elements of skin: inspection of the skin and palpation of skin and subcu tissue.

The full range of motion gives us one element of under musculoskeletal and that is assessment of range of motion left upper extremity.

In the 1995 evaluation and management documentation guidelines, they break the body into body areas and organ systems. In order to be able to bill for your higher levels of service, if it were a consult or a new patient, the level four or level five, you would want to make certain that you're indicating at least eight organ systems.

Again, the payers do have some different interpretations of the guidelines. But for the most parts, the level fours and fives talk about your organ systems and you cannot mix your body areas with your organ systems.

In the lower level E&M codes 2013, you are able to select one over the other. And in some payers, you're able to mix them. Again, you'll want to check with your local payers to see which process they would prefer that you do.

Our evaluation and management coding training expert states that usually, the best way to do that is maybe even to go on their website, pull their audit tools that they use and look at it in-depth to see how they would score things using body areas and and/or organ systems. But again, using those higher levels of service, you've got your organ systems represented.

One thing we also want to point out with that is you'll notice that eyes and then ears, nose, mouth and throat are separate. Oftentimes, especially in EMRs, we see headings that say HEENT or physician will write EEENT.

And when you see that heading, you can't just arbitrarily give credit for head, eyes, ears, nose and throat. You'll have to actually look at what documentation is next to that heading to determine what you're going to give credit for.

If it said HEENT and then it said ,Pupils equal, round reactive, then you would only really be able to give credit under the eyes section and not ENT or under head or face. If they said ,Pupils equal, round reactive to light and accommodation, and then they had ,(Ora fornix) is midline,, then you would be able to give eyes and ears, nose and throat.

Cardiovascular is usually where we put edema as auditors and coders. However, that's usually under the extremities or musculoskeletal section, cautioned our evaluation and management coding training expert. So again, it's important that you not only look at the headings that the physicians have included. But you also look at the specific documentation to make sure that you're putting the documentation into the appropriate slots in the audit tool that you might be using.

Moving further,  we break the levels of service down for the exam. We've got problem focused, expanded, detailed a comprehensive. You'll notice in comprehensive, the 1995 evaluation and management documentation guidelines specifically state that it has to be eight organ systems. In the 1997s, it's still talking about body areas or organ systems 18 plus elements.

Level four or level fives, for your new patients and for your consults. Level five for your established patients is where those fall. Otherwise, you've got the others.

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