Evaluation and Management Services
How to choose and use both 95 and 97 Documentation Guidelines for Evaluation and Management Services
A provider may use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management CPT or HCPCS Level II code for billing Medicare. However, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service for services performed on or after September 10, 2013.
The Elements Required:
History of Present Illness is a chronological description of the development of the patient?s present illness from the first sign and/or symptom or from the previous encounter to the present.
HPI elements are:
? Location such as left leg
? Quality as in aching, burning, radiating pain
? Severity such as 10 on a scale of 1 to 10
? Duration as in started 3 days ago
? Timing as in constant or comes and goes
? Context such as lifting of large object at work
? Modifying factors as in when heat is applied
? Associated signs and symptoms such as numbness in toes
How to choose wisely between the two Evaluation and Management Services
Brief and extended are the two types of History of Present Illness(es). Whereas a brief History of Present Illness includes documentation of one to three History of Present Illness elements, an extended History of Present Illness:
? 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities.
? 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions.