decisionhealth Newsletters, Coder Pink Sheets - 2014 Issue 7 (July)
Now you can swap in 97 HPI with 95 E/M documentation guidelines
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Article Overview
This article reviews Medicare and CMS guidance on evaluation and management documentation, focusing on how the 1995 and 1997 guideline sets differ and where each may be more useful in practice. It is aimed at coders, auditors, and clinicians who document E/M services, especially in settings involving Medicare patients and specialty-focused examinations. The article also references a CMS Q&A and discusses general documentation considerations for history and exam components.
Why This Topic Matters
Understanding the relationship between the 1995 and 1997 E/M documentation guidelines helps organizations review notes accurately and align documentation practices with Medicare policy. The topic is especially relevant for auditors and specialty practices that must assess whether documentation supports the level of service selected.
Article Sections
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Medicare policy update on E/M documentation guidelines
Introduces the CMS policy clarification and explains the overall relationship between the 1995 and 1997 E/M documentation approaches.
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How the guidelines differ in history and exam documentation
Summarizes the general differences between the two guideline sets and how they affect documentation of history and exam elements.
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95 exam documentation advantages
Describes situations in which the 1995 guidelines may be easier to apply and the types of encounters discussed in that context.
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When to use the 97 guidelines
Outlines scenarios where the 1997 guidelines may offer more structured documentation support or better fit certain specialties.
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CMS Q&A on mixing E/M documentation guidelines
Presents the CMS question-and-answer excerpt included in the article and the related policy clarification cited by the source.
What You Will Learn
- How CMS guidance affected the relationship between the 1995 and 1997 E/M documentation guidelines
- What broad documentation areas are emphasized by each guideline set
- Why certain specialties and encounter types may align better with one guideline set than the other
- How auditors may evaluate notes using the more favorable guideline set within Medicare policy
- What the included CMS Q&A says at a high level about combining guideline elements
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians and other clinicians documenting E/M services
- Medical practice managers
Codes Discussed
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