CMS Allows Combination of 95 and 97 E/M Guidelines

For 16 years CMS did not allow the 1995 and 1997 versions of their Documentation Guidelines for Evaluation and Management Services to be used interchangeably.  However, in September of 2013 CMS decided to modify this rule in a little known decision that is detailed in this article.  CMS now allows for history of present illness  (HPI) criteria that were limited to the 1997 Guidelines to be used for when determining the evaluation and management (E/M) level of service when using the 1995 Guidelines.  This is a significant change that could result in significantly higher E/M levels for many providers.

As background, the 1995 and 1997 Guidelines are very similar outside of how the level of service is determined for the physical examination; where they take vastly different approaches.  Otherwise the 1995 and 1997 Guidelines are identical with the exception of one seemingly minor, but actually highly impactful feature related to the HPI, as detailed below.

The 1995 and 1997 Guidelines have two levels of service for the HPI: Brief and Extended.  A HPI is determined to be brief when 1-3 of the following HPI elements are present:  Location, Duration, Quality, Severity, Associated Signs and Symptoms, Context, Modifying Factors and/or Timing.   In order to attain an Extended level for the HPI, 4 or more of these HPI elements must be documented.   The 1997 Guidelines allow for an additional method of attaining an Extended level for the HPI, that being when there was documentation of three or more chronic of inactive conditions and their statuses. Prior to September 10, 2013, this aspect of E/M coding could not be used to determine the level of service for the HPI if the provider was using the 1995 Guidelines.

The impact of this change is significant as many providers prefer to use the 1995 Guidelines as they are more comfortable with the degree of flexibility allowed for documentation of physical examination findings.   However, for specialties that manage multiple chronic diseases a high percentage of Brief HPIs based on the 1995 HPI requirements become Extended HPIs when the 1997 HPI guidelines are used.

In some practices, having providers take advantage of this unique feature in the 1997 HPI coding guidelines can result in substantially higher levels of E/M service coding levels.   Cardiologists, for example, frequently see patients with multiple chronic conditions but who do not have significant symptoms at the time of their visit.  Without significant symptoms or when symptoms are stable (e.g., “no change to frequency of intermittent chest pain) it is very difficult to capture 4 or more HPI elements.  However, during the same visit the cardiologist may have addressed the status of several chronic conditions (e.g., “Diabetes stable on current insulin regimen, COPD well controlled on medications with moderate SOB with exercise, intermittent atrial fibrillation has been chronic but not seen on recent monitoring, hypertension responding well to increase in diuretic dose.”)

In summary, CMS now allows for the documentation of three of more chronic or inactive conditions and their statuses in the HPI to qualify for an Extended level for the HPI for providers who use the 1995 guidelines to determine the E/M level of service for the encounter.  The HPI level of service is one of the strongest influencers of the overall E/M level of service, making this change of considerable benefit to providers.  Specialties that tend to manage multiple chronic illnesses (e.g., internal medicine, family medicine, cardiology, endocrinology, nephrology, oncology, and others) should take full advantage of this new ruling.

The text contained within the CMS Q&A that addresses this change reads:

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.



The link to the CMS posting from September 2013 is available here:  CMS FAQ on 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. 

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