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Last Modified: 11/27/2022 Location: FL, PR, USVI Business: Part A, Part B

Guidelines selection FAQ

Q: Why do I need to select which set of E/M documentation guidelines I prefer to use on the E/M interactive worksheet?
A: Evaluation and management (E/M) services refer to visits furnished by physicians and qualified, licensed, non-physician practitioners. Billing Medicare for a patient visit requires the selection of the code that best represents the level of E/M service performed. The purpose of the interactive worksheet is to assist providers with identifying the appropriate E/M code based upon either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services or AMA CPT E/M Code and Guideline Changes for 2021 (effective for office/outpatient visits only for dates of service on and after January 1, 2021).
Since the 1995 and 1997 guidelines or AMA CPT E/M Code and Guideline Changes for 2021 (effective for office/outpatient visits only for dates of service on and after January 1, 2021) each specify different criteria to determine the level of E/M service performed, only one set of guidelines may be used to document a specific patient visit. When applicable, the interactive worksheet offers providers the option to select either their preferred set of guidelines (1995 or 1997) or to select both for the purpose of comparison. For office/outpatient encounters, selections relating to the 2021 AMA revisions are also available.
When indicating a suggested code, the E/M interactive worksheet bases its calculations on the requirements specified in the guidelines and the selections made by the user.
The primary differences between the1995 and 1997 E/M documentation guidelines pertain to the requirements to qualify for specific History and Examination levels. For example, the 1995 and 1997 guidelines each specify different requirements to qualify for an Extended level of History of Present Illness (HPI), which is an element of the key component History:
1995 guidelines requirements for Extended level of HPI -- either four or more elements of the present illness or four or more associated comorbidities must be documented.
1997 guidelines requirements for Extended level of HPI -- either four or more elements of the present illness or the status of three or more associated chronic or inactive conditions must be documented.
Note: Effective September 10, 2013, for reporting services to Medicare, you may use the 1997 documentation guidelines for an extended History of Present Illness (HPI) along with other elements from the 1995 documentation guidelines to document an E/M service. However, the calculations performed by the E/M interactive worksheet and any E/M code suggested are based upon the selection of one set of E/M documentation guidelines for all key components and their associated elements.
In addition, the 1995 and 1997 guidelines also specify different requirements regarding possible examination types as well as criteria for each Examination level.
The E/M interactive worksheet offers providers the option to select either one set of guidelines (1995 or 1997) or both for the purpose of comparison:
Guidelines selection
Note: The options presented (e.g., 1995 and/or 1997 Examination sections) will automatically adjust based upon your selection (i.e., disappear or reappear). However, if the Both ’95 and ’97 Guidelines option is selected, all required sections of the E/M interactive worksheet -- including both the 1995 and 1997 Examination sections -- must be completed in order for the worksheet to calculate the suggested E/M code correctly.
Sources: 1995 Documentation Guidelines for Evaluation & Management Services
1997 Documentation Guidelines for Evaluation and Management Services
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