Differences in 95 and 97 EM Guidelines | E and M Coding

Coach Jennifer: Our question that came in –

Q: “There is always confusion for the new coder on the differences between the 95 & 97 E/M guidelines. Here are some simple facts to help you understand what sets them apart from each other.”
A: Yes, that is a lot of confusion there. We had some simple facts to put them apart. The question was they’re hearing about different sets of guidelines and how do we know which one to use and will they ask that? The CPC exam is what they meant.

Medicare is actually the ones who established these two different sets of guidelines. In 1995, they came up with the first set of guidelines. They’re pretty generic, it wasn’t directed towards any specialty at all. It became a little confusing for most people because the exam component of that E/M level it didn’t specify how to distinguish between an expanded problem focused and a detailed exam; so you have four different levels on exam but two of them were almost the same. So, the expanded problem focused set a limited examination of the affected body area or organ system and other symptomatic or related organ systems, where a detailed was an extended exam of the exact same thing.
So, what’s the difference between a limited and extended? A lot of people were having problems, say cardiology, or neurology, some other kind of specialties because they can’t really get all of these body areas or organ systems because they’re mainly dealing with one. So, in 1997 they came up with a new set of guidelines that was almost the same, but when it came to the examination, they included a specialty or they were organ-specific exams. Then gave you box or checklist or bullets that you would meet to pick your E/M level.

So there’s another difference between the two, was in the history of present illness. So in doing your HPI, when you’re looking at an extended HPI, the 95 guideline said that it should describe four or more elements of the present HPI or associated comorbidities. But the ’97 guidelines gave that a little bit more difference; you need those four or more elements or at least four elements or the status of at least three chronic or inactive conditions.
So you think of those cardiologists or the primary care doctor or somebody in that field. They see these people constantly or every month or every six weeks or so for their diabetes, for the high blood pressure, things like that. At least, if they’re following up their three chronic problems, then they could meet that qualification as well.

Providers can actually choose between ’95 and ’97 guidelines. We talked about this a lot as it should be in your compliance manual as to which one you follow. That way, in case there’s audit they already know that you like to follow the ’95 guidelines. But it’s whichever is most advantageous; so if you use the online Medicare tool, they usually default to ’95 because it becomes a little bit more advantageous for people, which you have to use one guideline or the other. You can’t mix both; you can’t use one part, it’s one or the other.

When you’re doing the CPC exam, they’re not going to ask you to level an E/M. They’re going to say, they’ll present the question and then they’ll give you criteria and they want you to pick the E/M. So, something like: The patient is seen in the hospital for follow-up visit. They did a detailed history, detailed exam and the medical decision making was high complexity. So, what code? Then, a, b, c, d; they’ll give you those codes. It will be something like that.
They’re not going to say the patient was seen on this day for these problems and what level is it. When they get more detailed like that, that’s going to be your certification exam for a more detail like the CPMA for the medical auditing exam or perhaps the CEMC which is a specialty of just the evaluation and management. That’s where they’re going to have you look at it and wants you to actually level an E/M.

They usually suggest you have at least two years of experience before you try to be a CPMA or something they want you to see these things. It really takes repetition going over and over and you need to have these done often enough to know what you’re looking for. So, one of the exams for those, they might tell you in the question: “a coder used 1995 guidelines” or “answer this question using the 1997 guidelines.” So, you’re able to bring those sheets in with you that tell you the guidelines to those more specialized certification exams. But on the CPC exam they’re not going to ask you to level those.

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