Mix and Match E/M Guidelines to Help Your

Coding Levels
By Susan Dooley

There was a time that your providers had to choose history of present illness documentation criteria
from either the 1995 or 1997 Documentation Guidelines for Evaluation & Management Services based
on the guidelines used for the other E/M elements they couldnt mix and match between the two
standards. But those days are gone. CMS says providers filing Medicare claims no longer have to stick
with the 1995 standard or the 1997 standard throughout the report instead, they can use the 1997
documentation guidelines for an extended HPI along with other elements from the 1995 guidelines to
document an E/M. And this flexibility also gives your provider a better chance of meeting the level of
service indicated to report a higher E/M code.

Review Differences Between 1995 and 1997 Standards

HPI, or history of present illness, documents how a patients presenting illness developed, from the first
sign or symptom to the current encounter. Under the 1995 guidelines, to assess the level of HPI to
assign the E/M code level, you count the number of HPI elements reviewed and documented by the
provider.

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

The 1995 guidelines include eight elements: location, quality, severity, duration, timing, context,
modifying factors, and associated signs and symptoms.
Using 1995 guidelines for History E/M coding, a brief HPI describes one to three of these elements; an
extended HPI describes four or more elements or associated comorbidities, which can be documented in
the past medical history, review of systems, or in the HPI.
Using the 1997 guidelines for E/M, youd choose the HPI level based on the number of the eight HPI
elements documented, as in the 1995 guidelines. Alternatively, the 1997 guidelines allow you to
consider the number of chronic or inactive conditions your provider reviews with the patient. A brief HPI
has one to three elements, and an extended HPI has four or more elements, or it includes the status of
at least three chronic or inactive conditions.

How Does the Mix and Match Combination Work?

Before this change was announced, you had to use either the 1995 or the 1997 guidelines to evaluate
the entire encounter for E/M purposes. But now the provider can use 1997 guidelines for the HPI and
the 1997 guidelines for the physical exam portion (and everything else) and still meet the criteria.
For example, say your physician documented three HPI elements and the status of three chronic
conditions, and performed and documented a comprehensive Review of Systems and Past Medical,
Family, and Social History (PFSH). Though the encounter didnt document four HPI elements, the
physician still gets credit for a comprehensive HPI because she included the status of the three chronic
conditions. Then the physician performed a physical examination with four in-depth findings for
constitutional, eyes, ENT, and neurologic exams. This is called a 44 exam, which doesnt mean that your
provider drives a pickup truck with four-wheel drive, but rather that the physical exam reported four
specific in-depth findings about four body systems. For payers, a 44 exam helps differentiate between
the expanded problem-focused and the detailed exam.
In the case of this exam, because you have a comprehensive history (based on the 97 guidelines for HPI)
and a detailed exam (based on the 95 guidelines), youre almost home free for submitting 99214. As
long as this is an established patient and the visit was medically necessary, which should have been
made clear by the patients chief complaint, you can submit 99214 without even considering medical
decision making (MDM) factors.

What About You?

Have any tips for E/M coding success? Write to us!

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Want to avoid any evaluation and management coding complications and be extra sure your code
reporting complies with E/M guidelines? Automate that tedious E/M auditing with SuperCoders EM
Auditor. Quick screen navigation gives options to assign levels to the key components or time for coding
or auditing. You can even choose between the 1995 and 1997 E/M guidelines, and EM Auditor will tell
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

you if reimbursement would be higher with the other set of guidelines. Learn more, and contact us for
free trial!

Contact Us:
Name: Sam Nair
Title: Associate Director Enterprise Practice
Email: shyamn@codinginstitute.com
Direct: 704 303 8150

Desk: 866 228 9252, Ext: 4813

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com