Avoid 1995 and 1997 E/M Guidelines Misuse – or Face 2021 Overpayments

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Avoid 1995 and 1997 E/M Guidelines Misuse – or Face 2021 Overpayments

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1995 and 1997 EM Guidelines

When documenting medical records, CMS has two sets of established evaluation management (E/M) documentation guidelines that will be replaced in 2020.

You’ve got to understand the key foundations of the current guidelines to be able to learn and understand the upcoming replacement rules – or risk facing thousands in overpayments. E/M codes will change for the first time in more than 20 years.

You currently use 1995 and 1997 E/M guidelines guidelines that CMS created as guides to the original E/M codes. Knowing which guideline to use and why is the key to properly documenting and appropriately coding your E/M visits — not to mention avoiding overpayments.

Choosing between 1995 and 1997 E/M Guidelines

The good news is that when billing for Medicare services, providers may use either version of the guidelines to document a patient encounter, you just can’t select to use them both. However, “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,” explains CMS.

1995 and 1997 E/M Guideline Differences

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, they can be more challenging to get enough credit to attain a higher level of service. We’ll explore the evaluation and management components and point out the main differences between and some best practices for using the 1995 and 1997 E/M Guidelines.

Evaluation and Management of Key Components

There are 3 key E/M components you use when choosing the proper codes for billing. These include:

  • History – Outlines the chief complaint (CC), details a history of present illness (HPI), provides a review of systems (ROS), and includes a past family and social history (PFSH).
  • Examination – Assesses body areas or organ systems and, along with the medical history, helps to determine the correct diagnosis and devise a treatment plan.
  • Medical decision making – Refers to the complexity of establishing a diagnosis and/or selecting a management option

** The two primary difference between the 1995 and 1997 E/M guidelines are the HPI and the examination.

2021 Change: E/M selection will be based solely on time or medical decision making.

1995 and 1997 E/M Guidelines – History of Present Illness Differences

The physician’s ancillary staff may document the Review of Systems and Past, Family, Social History, but the provider must personally document History of Present Illness. 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:

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs & symptoms

An extended HPI documents four or more elements of the present HPI or associated comorbidities, under the 1995 E/M guidelines. 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:

  • DM type 2, well controlled with diet
  • Hyperlipidemia, patient is attempting to control with dietary changes, however, levels are still elevated
  • HTN controlled with Toprol

1995 and 1997 E/M Guidelines – Examination Differences

There are four types of examinations that determine the level of E/M services:

  • Problem Focused – limited examination of affected body area or organ system
  • Expanded Problem Focused – limited examination of affected body area or organ system plus any other symptomatic or related body area(s) or organ system(s)
  • Detailed – extended examination of affected body area(s) or organ system(s) plus any other symptomatic or related body area(s) or organ system(s)
  • Comprehensive – multi-system examination or complete examination of a single organ system (plus other symptomatic or related body area(s) or organ system(s), per 1997 guidelines).

The main examination documentation differences are:

  • 1995 guidelines – document body areas and/or organ systems; more subjective which can lead to confusion. For example, what if the information you have is labeled as an organ system but it’s really a body area? Tip: Check with your Medicare contractor to see how they handle these situations should they arise.
  • 1997 guidelines – document predetermined/individual bullet points; more rigid. For example, specific bullet points for Respiratory include:
  • Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
  • Percussion of chest (e.g., dullness, flatness, hyper resonance)
  • Palpation of chest (e.g., tactile fremitus)
  • Auscultation of the lungs

    Tip: 1997 guidelines benefit specialty-specific documentation

em guidelines

Template Tips

Templates are beneficial for documenting E/M visits, and you can even design them to fit your practice. But use caution or they can be a smoking gun. When using templates:

  • Ensure the template indicates who enters the information.
  • Verify that you are really doing everything described in the bullet item.
  • Avoid contradictions and reconcile any that rise.

Tip: Templates are often based on 1997 guidelines. So, if you are using the 1997 guidelines, consider using templates that have clinically relevant bullet points.

2020 Change: providers will still need to document elements of history and examination, but they will not need to count them to determine the supported level of E/M code. This allows medical necessity and medical decision making – or time – to drive the code selection. Some providers worry that they may code lower levels overall using the new system. Find out if this is true in the upcoming E/M training sessions.

E/M Documentation Pitfalls and Audit Concerns

A lot of confusion can arise when documenting E/M visits. For example, the 1995 E/M guidelines allow for a single system comprehensive exam, but it doesn’t define what that is. Also, the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). One of the biggest concerns when documenting E/M visits is being audited. You can better prepare for audits when you document with auditing in mind to begin with.

What are auditors looking for?

  • Authentication – signatures, dates/times, identification of who did what
  • Contradictions – between HPI and ROS, exam elements
  • Wording or grammatical errors/anomalies
  • 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. Instead, simply state that you follow the documentation guidelines. In that case, the auditor has to audit you under both and give you credit under whichever you do better under.

Don’t clone notes: Good notetaking is imperative. Stay away from cloned notes in an attempt to speed up the process. Notes that are too similar from one patient encounter to the next don’t support medical necessity, might not support that a visit occurred, and may actually be seen as an attempt to defraud Medicare.


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