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faq #3
 

 

FAQ #3
       
What are the differences between the 1995 and the 1997 E/M guidelines?

Answer: Unfortunately, this is a complicated question and the answer may depend upon who you ask.

The best way to consider this question is to take apart the key components of documentation.

HISTORY: The rules for documenting the PAST MEDICAL, FAMILY and SOCIAL HISTORY and REVIEW OF SYSTEMS are identical for both the 1995 amnd 1997 E/M guidelines. The sole difference lies in the documentation of the HPI. The 1995 rules state that you must use the HPI elements to complete the HPI. A BRIEF HPI requires one to three of the HPI elements while an EXTENDED HPI requires at least four HPI elements. But, there is some language in the 1995 rules that also leaves the door open to documenting an EXTENDED HPI by commenting on four "associated co-morbidities." To be honest, it's not really clear if you can use the co-morbidities or if you have to use the HPI elements when completing the HPI using the 1995 rules. On the other hand, the 1997 E/M guidelines clearly state that you can qualify for an EXTENDED HPI by documenting four HPI elements OR by commenting on "the status of three chronic or inactive conditions."

PHYSICAL EXAM: The rules for documenting the exam are very different for the 1995 and 1997 E/M guidelines. The 1995 rules are pretty vague and rely on the documentation of various numbers of BODY AREAS and/or ORGAN SYSTEMS. It is very difficult to know for sure what exactly is required for each level of physical exam. On the other hand, the 1997 E/M guidelines state that the exam must be documented using specific BULLETS. The different levels of physical exam require a specific amount of bullets from the various organ systems. There are also several SPECIALTY EXAMS designed to contain relevant bullets from different specialties.

MEDICAL DECISION-MAKING: The rules for documenting the key component of medical decision-making are identical for both the 1995 and 1997 E/M guidelines.

 
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