E&M Services 1995 vs 1997 Guidelines

 

1^st published November 21, 2005

 

You may follow either the 1995 or 1997 guidelines in determining the appropriate level of service. In comparing the guidelines, changes to 1997 are as follows:

HISTORY – In 1997, an extended HPI includes the status of at least 3 chronic or inactive conditions. This is the only change.

EXAMINATION – In 1995, only the multi-system examination was defined. In 1997, the documentation requirements for the multi-system exam have changed (see chart below) and 10 single organ system examinations have been developed.
DECISION MAKING – No changes

General Multi-System Examination

Type of Examination	1995	1997
Problem Focused	Limited exam, affected area/system (one)	1 to 5 bullets
Expanded Problem Focused	2 to 7 systems	At least 6 bullets
Detailed	2 to 7 systems (more detail)	At least 2 bullets from each of 6 areas OR at least 12 bullets in 2 or more areas
Comprehensive	8 or more systems	Perform all bullets in at least 9 areas and document at least 2 bullets from each of 9 areas

1995 – For purposes of examination, the following body areas are recognized:

§         Head, including the face

§         Neck

§         Chest, including breasts and axillae

§         Abdomen

§         Genitalia, groin, buttocks

§         Back, including spine

§         Each extremity

1995 and 1997 – For purposes of examination, the following organ systems are recognized:

§         Constitutional (e.g., vital signs, general appearance)

§         Eyes

§         Ears, nose, mouth and throat

§         Cardiovascular

§         Respiratory

§         Gastrointestinal

§         Genitourinary

§         Musculoskeletal

§         Skin

§         Neurologic

§         Psychiatric

§         Hematologic/lymphatic/immunologic