E&M Guideline Updates

Question: We recently had a compliance administrator question why we were using "old data" to audit physician charts. She was referring to the 1995 and 1997 federal guidelines. Are there newer rules we should use?

Answer: Not from CMS itself. The Evaluation and Management Service Guide online directly references the 1995 and 1997 guidelines, although it does include some later, slightly more definitive information.

A better question is whether or not they are the best source or tool to evaluate your providers. For Medicare each carrier or MAC is allowed to interpret these rules their own way, and many have their own E&M evaluation tool. Some are on their Web sites, some not. Look at your carrier’s Web site to see if they have a specific tool for your state or region, or call them and ask. But if they don’t - we all default to the 1995 and 1997 guidelines. Old isn’t necessarily bad.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This question originally appeared in the November 2010 issue of Physicians Practice.