Mixing the E&M guidelines

February 1, 2008

We decided to have a certified coder review our charts to help us straighten out any coding and documentation problems. The auditor used the 1995 evaluation and management guidelines. She told me that when I documented the exam portion of a visit, I included both body areas and organ systems in the note and that's inappropriate. I can't see why that's a problem. Is she right?

We decided to have a certified coder review our charts to help us straighten out any coding and documentation problems. The auditor used the 1995 evaluation and management guidelines. She told me that when I documented the exam portion of a visit, I included both body areas and organ systems in the note and that's inappropriate. I can't see why that's a problem. Is she right?

Yes, she is. The CMS E&M guidelines indicate that you shouldn't combine body areas and organ systems in the same note-you have to use one or the other.

And remember, too, that even though you can use either the 1995 or 1997 guidelines when you notate your services-depending on which one you find to be the most beneficial-you can't mix and match them when documenting the same visit. For example, you can't use the 1997 guidelines for the history and the 1995 guidelines for the exam during the same service.