tci General Surgery Coding Alert - 2003 Issue 7

Reader Questions: Take Your Pick of 95 or 97 Guidelines

Question: Which guidelines for E/M documentation (1995 or 1997) should we use when reviewing chart dictation?West Virginia Subscriber Answer: You may choose either the 1995 or the 1997 documentation guidelines for E/M services. Medicare has stated that it will check E/M coding against both documentation guidelines before deciding whether you have met the recorded level of service. Physicians are not constrained from switching back and forth to suit the situation or their mood. In 1995, CPT developed E/M guidelines to define the intensity of medical service delivered while maintaining some flexibility to accommodate the natural variations found...

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