EM guidelines for 95 versus 97. The first person wrote, “I see EM guidelines 95 and 97 used in prep test for the CPC. Can you explain what these guidelines are? I’m not sure what these are.” And then number 2: “Can some doctors in our hospital like general practitioners and internal medicine doctors document their outpatient visits according to 1995 guidelines and at the same time, general surgeons, urologists, OBGYN, eye and ENT specialists document their outpatient visits according to 97 guidelines? So ultimately, when the external audit occurs, how do these… how these charts can be audited according to 95 guidelines or 97?”
So let’s take a look at the answer sheet I prepared.
EM Guidelines 95 and 97 – VIDEO
Laureen: Yeah. So what I did is I took a screenshot of my actual manual because I do like you know, when I teach everything, to take you right to the book versus just typing a whole bunch of stuff on a slide. So you can really see things in context. So in your CPT manuals, you have this in the E&M guidelines and there’s this step here, “Determine the extent of exam performed.” I have it labeled number 2 because the first step is figuring out the history. And there’s 4 levels in the CPT manual and this way of doing E&M came about in 1992. So if you… don’t’ really call it 92 guidelines but just to give you a little history, that’s when it started.
So they’ve got 4 scores that you can have. 4 scores? Never mind. Problem focused, expanded problem focused, detailed or comprehensive. Now, part of my technique when I’m teaching E&M is I teach you to convert these phrases to one letter so P,E,D,C – problem focused, expanded problem focused, detailed, comprehensive. So this is what doctors had to first start with. Prior to that, they were just coded by time. “Oh, 10 minutes? It’s a level 1. 20 minutes is a level 2.” The higher the level, the more money. So they came up with these guidelines and this is the problem.
If you… problem focused is easy. It’s a limited exam of the affected body area or organ system. So if they come in with pain in their knee, well the doctor isn’t going to do a full workup. They’re just going to focus on their knee. So that will be problem focused.
Expanded problem focused, it’s a limited exam of the affected body area or organ system and other symptomatic or related organ system. So I call it a limited plus. So it’s that one organ system, the reason they came in, and maybe one more. For example, if a patient comes in with a headache, it could be stress related or could be something very serious like a tumor. So they might do a neurological type of questions and look at a couple organ systems to try and figure out what they’re dealing with.
Then a detailed level of exam is an extended exam of the affected body area and other symptomatic or related organ systems. This is almost word for word the same as expanded problem focused. But the only difference is limited versus extended. That’s really the only difference. And then comprehensive is a general multisystem exam or a complete exam of one organ system.
So the problem focused is easy. The comprehensive is easy to figure out. But doctors were like, “Well, how do I know limited versus extended?” That’s kind of nebulous. So that’s when they came out with the 97 guidelines. So what we just read here is basically the 95 guidelines , without going into a whole 3-hour E&M lecture. You’ve got your 3 key components: history, exam and medical decision-making. The difference between 95 and 97 guidelines is primarily dealing with this exam issue. There are a few little nuances of difference in the history and medical decision making but a bulk of it is what we just discussed. Okay so that’s kind of like the 95 versus 97.
And when they talk about body areas or organ systems, they’re listed right in CPT for you. So here are the body areas: head, neck, chest, abdomen, genitalia, groin, buttocks, back, each extremity. So what you want to understand here since we’re talking about it is these bullets are kind of literal. So if you have each extremity… so the right arm would count as one bullet or if you were doing an audit, you’d have a… your little check box. Left arm, one checkbox. Right leg, one checkbox. Left leg, one checkbox. So each extremity… so this could be up to 4. But chest, including breast and axilla, if all 3 of them are looked at, this just counts under this one bullet.
And then organ systems are here, eyes, that’s one bullet. Ears, nose, mouth and throat all count as one bullet. It’s not 4 different things. It counts as one bullet for adding up the exam stuff. So I just want to give you that little tidbit there.
Another website that I like to use a lot is EM University and let me take you there. emuniversity.com and the link is /physicalexam.html.
But there’s a general multisystem exam for 97 and then there’s one for like psychiatry. There’s one for cardiology. And so when you’re a physician in that specialty, you could choose to use the 97 guidelines very detailed. And you have to add up so many bullets and get your score to go back to that.. to back into… was it problem focused, expanded problem focused, detailed or comprehensive?
Now the questioner was asking, “Can you use both? Can you mix and match?” And the answer is yes. You’re allowed to use whichever guidelines to give you the best outcome. Let me go back to the question real quick.
So on the board exam; they don’t go into too much detail with the 97 guidelines, not for the CPC exam. Now if you’re sitting for the E&M Specialty exam, yes. You bring your audit tools and you do all those little check box thingies. For the CPC exam, the CPC-H exam, they’re testing you more what’s on the CPT in the CPT manual. And they try and stay away from these real grey areas so they’ll tend to use things like the general multisystem exam so you could go, “Oh okay, that’s comprehensive.” And you can plug it in. But it is… you should understand generally that there are these different guidelines out there. You’re allowed to use whichever one is best for you. So if you get a higher level using 95 versus 97, you can go ahead and code based on that.
And then for the second question, yes absolutely. You can have some using 95 guidelines, some using 97. You’re totally allowed to do that. The intent was to have the 97 supercede the 95 but that didn’t happen. It didn’t work out that way. And they’ve tried to come up with new guidelines ever since and that kind of failed. But a lot of what really drives it is the medical decision making. And they do want to come up with a new system; I just don’t know how long it’s going to be before they can do that.
Okay so I think I covered everything on my slide here. Oh and for those in the Replay Club, they’ll get this answer sheet. You can go right to the official 95 and 97 E&M guidelines just to give you an idea of what it looks like. It’s cms.gov and they’ve got this outreach and education Medicare Learning Network thing. And this is a PDF so you can print it but it’s very long. But what I did when I first learned this is I printed out, I put it in a binder and I had my 95 and my 97 guidelines. But these are the official guidelines on the CMS website.
In addition, they’ve got this Medicare Learning Network EM Guide. So if you’re kind of new to learning E&M coding, this is a nice, detailed primer if you will on E&M coding given by CMS. And they’ve got some pretty good education material. I don’t know why this has taken so long.
Laureen: So that’s the E&M guidelines, 95 and 97. That’s a real rush job. Someone in the chat was asking if we have training on E&M. Yes, we do. We have an on demand E&M class. It’s 3 hours. It’s worth 3 CEUs and we kind of go into this in a little more detail. So you can check that out on the website.
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