What is the Difference Between the Medicare 1995 and 1997 Documentation Guidelines for E/M Services?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Oct 12th, 2020

When Medicare determined that providers could follow EITHER the 1995 OR the 1997 Documentation Guidelines for Evaluation and Management Services to determine which level of E/M service to report, because CMS had not clarified that portions of the 1995 and 1997 guidelines could be used together to determine the level of E/M to be reported, many of the Medicare Administrative Contractors (MACs) and private payers who follow Medicare's guidelines added the rule:

Do Not Mix and Match the Guidelines

In other words, each E/M encounter service would have to strictly follow either the 1995 or the 1997 guidelines and not take bits and pieces from each set to determine the level to report. 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.

HISTORY

History is based on the presence and extent of information documented in a chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past medical, family, and social histories (PFSH).While the CC, ROS, and PFSH remained the same, the history of present illness (HPI) guidelines changed in 1997, as follows:

• 1995: An extended HPI consists of at least four elements of the HPI.
• 1997: An extended HPI consists of at least four elements of the history of present illness (HPI), or the status of at least three chronic or inactive conditions.

EXAMINATION

Examination is based on the amount of information documented within specified body areas (7) OR organ systems (12). The 1995 guidelines were specific but for many, not specific enough; however, when the 1997 guidelines were released, the specificity for scoring the examination portion was overwhelming for many, which is the main reason for the ability to use either the 1995 or 1997 guidelines.

• 1995: Scoring was determined by the number of organ systems examined (no detail provided about what constituted an examination within an organ system) or the number of body areas examined. Providers could not count both organ systems and body areas, just one or the other for their score.
• 1997: Scoring was determined by which examination was performed and twelve different examinations were introduced (General Multisystem and 11 Single Organ System examinations) and each organ system or body area within each of these examinations contained bulleted examination requirements.

MEDICAL DECISION MAKING

MDM is based on information documented about the number of possible diagnoses and/or management options being considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications, morbidity, and/or mortality, and comorbidities associated with the patient’s presenting problems, diagnostic procedures, and/or possible management options. The score is based on two of three subcomponents of MDM (diagnoses, data, risk) meeting the level of complexity.

• 1995: Straightforward, Low, Moderate, or High Complexity
• 1997: Straightforward, Low, Moderate, or High Complexity

In other words, the guidelines affecting how the MDM is scored did not change between 1995 and 1997. On September 10, 2013, a new guideline change was published.

The Department of Health & Human Services published the following: “FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services.” This published FAQ included just a single question with an answer:

Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code? A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. 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.

Essentially, could a provider take the elements of both the 1995 and 1997 guidelines where they scored best to determine the level of service? While the answer to this question was no, they cannot use a combination of the two to determine their score, it brought to light differences between them (other than the examination) that would cause a provider to want to combine them for scoring purposes. The answer to that question was also answered in the FAQ with the following statement:

...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.

To understand this, you first have to understand that the history of present illness (HPI) is scored as “brief” or “extended.” A brief HPI consists of 1-3 elements (the same in both 1995 and 1997) while an extended HPI is scored differently: 1995 (1-4 elements) 1997: 1-4 elements OR the status of at least three chronic/inactive conditions. The release of this official FAQ from the DHHS changed the dynamic of what is different between the 1995 and 1997 guidelines, as noted in the table below. The highlighted portions under each year identify what is different from the prior guidelines.

When CMS published guidelines without expanding upon them, the responsibility of providing clarity often falls on the shoulders of the Medicare Administrative Contractor (MAC), who processes the Medicare claims for beneficiaries who receive services from providers within their geographic location. Historically, several MACs have had strict rules preventing providers from combining the 1995 and 1997 guidelines for scoring purposes, while others have not. This has caused many headaches with educating, training, and compliance just to keep the guidelines straight. With the release of this FAQ, suddenly clarity from the CMS was given on the topic and could become uniform. If a single MAC had released the information, then it would be applicable only to those provider services governed by the particular MAC; however, because the DHHS (which governs CMS) released the information, it is applicable to all providers and MACs. The change became effective on September 10, 2013, so claims prior to this date are still accountable to the prior guidelines. Private payers who follow Medicare guidelines may be a little slower to make this change; however, if they claim to follow Medicare's guidelines, you can fight the good fight by keeping this document handy, if it is the issue brought up in an audit.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.