CMS recently posted an E/M documentation policy change regarding the use of both 95 and 97 E/M guidelines.

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.

To view the original FAQ from CMS click here

As a reminder, the History of Presenting Illness, HPI, is a chronological description of the development of the patient’s presenting illness or problem from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

Location (eg. diffuse, localized, unilateral, bilateral fixed, body area)
Quality (eg. sharp, dull, throbbing, chronic, aching, burning, radiating)
Severity (eg. on a scale of 1-10, more or less)
Duration (eg. started 3 days ago, since last visit)
Timing (eg. constant, comes and goes)
Context( eg. lifted an object)
Modifying factors (eg. better when heat applied)
Associated signs and symptoms (eg. hurts to swallow)

An Extended history of presenting illness (HPI) for the 1995 E/M guidelines requires 4 or more elements be documented on the encounter. For the 1997 E/M guidelines, an extended HPI consists of 4 or more elements OR the status of 3 chronic or inactive conditions be documented in the encounter.

An example of an Extended HPI using the 1995 E/M guidelines capturing 4 or more elements: Ben’s sugars have been extremely high for over a week and are worse in the afternoon. It makes him dizzy and nauseous when this happens. Once he takes his insulin they drop back to normal.

Duration OVER A WEEK
Modifying factors TAKES INSULIN
Associated signs and symptoms DIZZY AND NAUSEOUS

An example of an Extended HPI for the 1997 E/M guidelines capturing the STATUS of 3 Chronic or inactive conditions.
Ben is here for follow up of his type 2 Diabetes which is currently uncontrolled. He continues to struggle with hypertension however, his hyperlipidemia is currently controlled well with exercise and medication.

The complete 1995 E/M Guidelines are found here
The complete 1997 E/M Guidelines are found here

AACE continues to encourage members to check with their local Medicare Administrative Contractors, commercial payers and/or compliance departments to determine if there are additional guidelines required when documenting professional services.


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