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Ask-A-Consultant: E&M Coding


I am the administrator for a 4 physician practice. My physicians are really confused about the various documentation guidelines for evaluation and management services and donít know which ones to follow. One of the physicians is still utilizing the 1994 guidelines, 2 are utilizing the 1997 guidelines and one just codes whatever he feels like his visit is worth. Which set of guidelines do you recommend?


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As you know, every evaluation and management service is made up of three key components: history, examination and medical decision making. The only difference between the 1994 and the 1997 guidelines is in the examination component.

The 1997 guidelines consist of 11 specialty examinations and one general multisystem examination. Each have specific elements that must be documented for a specific level of examination (problem focused, expanded, detailed or comprehensive). In contrast, the 1994 guidelines are much more general and are based upon body areas and systems, but not specific elements of the body area/system.

Many of the specialties prefer the 1997 guidelines, as they are much more explicit about the information that is required. One can simply count the number of elements documented to arrive at the level of service for the examination component. On the other hand, many primary care physicians, particularly pediatricians, prefer the 1994.

Since the evaluation and management services documentation guidelines are still under evaluation and revision, neither the 1994 nor the 1997 guidelines are final. Therefore either set may be utilized. We advise practices to allow their physicians to utilize the guidelines with which they are most comfortable. The most important thing to remember is that everyone in the practice should be consistent with the particular set of guidelines chosen. In fact, in the event of an audit by your Medicare carrier, both sets of guidelines will be utilized. Auditors are instructed to utilize the guidelines that are most beneficial to the practice.


Mary Beth Black, CPC (bio...)
Senior Associate

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