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Physician documentation audits: Can 1995 and 1997 E/M Guidelines be combined?


Our office is starting to do a monthly audit of our physician charts. We’re going to be looking at documentation and coding to make sure they are on the right track. When we’re conducting these audits, do we have to use either 1995 or 1997 guidelines or can we combine the two?


Renee StantzQ: Our office is starting to do a monthly audit of our physician charts. We’re going to be looking at documentation and coding to make sure they are on the right track. When we’re conducting these audits, do we have to use either 1995 or 1997 guidelines or can we combine the two?

A: Historically, the Center for Medicare and Medicaid Services (CMS) has instructed that one of the Evaluation and Management (E/M) Guidelines had to be used-either 1995 or 1997-when charts were reviewed, internally or externally. 

Recently, however, they have changed (and I believe advanced) their instruction to state that, “… beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness (HPI) along with other elements from the 1995 guidelines to document an evaluation and management service.” 

The full article, “Medicare E/M FAQs,” can be found at: http://go.cms.gov/16F3HBY.

Let’s discuss what this means exactly and how it will benefit your physicians and non-physician practitioners (NPPs) in their reviews.

First, let’s review the differences and similarities between the two guidelines.

1995 versus 1997 E/M Guidelines

There are not too many differences between the 1995 and the 1997 guidelines and there are some similarities. Let’s discuss both of the guidelines now. 

Two major differences exist between the 1995 and 1997 E/M guidelines:  HPI and the exam element. 

The following criteria are the same for the 1995 and 1997 E/M guidelines, including: The Review of Systems; Past, Family and Social History; and Medical Decision Making.

Now, let’s delve into the two major differences: HPI and the exam.

History of present illness

The HPI is arguably one of the most important pieces of E/M visit documentation because it, in conjunction with the chief complaint, supports medical necessity for the visit.  It is described in the Current Procedural Terminology (CPT) guidelines as “a chronological description of the development of the patient’s illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

  • location,

  • quality,

  • severity,

  • duration,

  • timing,

  • context,

  • modifying factors; and

  • associated signs and symptoms.

For an extended HPI, the 1997 E/M Guidelines also allow for “the status of at least three chronic or inactive conditions.”

Until September 10, 2013, CMS had strictly interpreted the guidelines and only allowed the status of at least three chronic or inactive conditions when utilizing the 1997 E/M Guidelines.  However, physicians/NPPs and reviewers now can “mix” the guidelines in so far as credit can be given in the HPI for the elements listed above or the status of three chronic or inactive conditions regardless of which set of guidelines being utilized.

For years, reviewers have thought that credit should be given to physicians/NPPs for the status of chronic conditions for either set of guidelines. This is because it takes the provider’s time and medical knowledge to review the patient’s chronic conditions, and this type of thoroughness is simply good patient care. 

The guidelines state that reviews should be conducted so that the physician/NPP obtains the most favorable outcome, and allowing for the review and status of chronic conditions in the HPI further advances this goal.

Exam Element: 1995 guidelines

While most of the guidelines remain the same between the two versions, the exam component is very different. The 1995 guidelines include a one-size-fits-all multi-system exam that recognizes body areas and organ systems.

In contrast, the 1997 guidelines not only offer a general multi-system exam, but also single organ system examinations for:

  • cardiovascular,

  • ear, nose and throat,

  • eye,

  • genitourinary,

  • hematologic/lymphatic/immunologic,

  • musculoskeletal,

  • neurological,

  • psychiatric,

  • respiratory, and

  • skin.

Without question, the 1995 guidelines are much more straight forward and are easier to use for physicians/NPPs and reviewers alike.

 However, specialty physicians and NPPs sometimes find that single organ system exams are better suited to document their specific specialty elements, while general practitioners tend to lean toward the 1995 general multi-system exam because they don’t normally need the specificity that the single organ system exams offer. Physicians/NPPs and reviewers can-and should-choose the examination that most benefits the physician or NPP. 


The answer to our reader’s question was provided by Renee Stantz, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your practice management questions to medec@advanstar.com.


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