Medical Billing 101: What Are the 1997 E/M Guidelines?

Discover key distinctives of the 1997 E/M coding rules and why they matter.

A lot was new in 1997. Titanic was a new box office blockbuster. Steve Jobs was back at Apple as the company’s new CEO. Harry Potter was a new star in children’s literature.

Here’s something else that was new—the Medicare billing E/M guidelines of 1997.

That year, the Health Care Financing Administration (renamed the Centers for Medicare and Medicaid Services, or CMS, in 2001)—put into effect revised rules for documenting and coding patient encounters that involve evaluation and management (E/M) services. These guidelines were intended to replace those previously implemented in 1995.

E/M services are, as MDCodePro founder Dr. Alexander Stemer points out, the services physicians most frequently deliver. So people might assume physicians routinely learn these rules. But you, a busy and responsible medical practitioner, already know that assumption is wrong.

More than 20 years later, the 1997 E/M Medicare billing rules still raise a lot of questions for a lot of healthcare professionals. Here are three basic questions, with answers that will help you get a handle on these important guidelines.

e m guidelines 1997

  1. Why did new CMS medicare guidelines appear two years apart? Two years isn’t a long time. But two years was long enough for physicians and coders to realize that while CMS’ 1995 documentation rules gave much-needed direction for using CPT® E/M codes correctly (they’d only been introduced in 1992,) problems remained.One was that the guidelines sold medical decision-making (MDM) short. Of the three key components in patient encounters—the medical history, the physical exam, and the provider’s MDM—MDM should, as Strategies for Nurse Managers put it, “be at the heart of E/M code selection,” justified by the other two because it “speaks directly to medical necessity.” But the 1995 rules left the elements of MDM “relatively vague” when compared to their detailed breakdowns of the history and the exam. This vagueness led to undercoding, and physicians being undercompensated.Another problem, related to the first, was that some practitioners fared better than others under the 1995 rules. Healthcare compliance consultant Jean Acevedo writes, “[P]hysicians felt that [the 1995] guidelines favored internists and other primary care physicians, particularly in the exam component.” The 1997 E/M rules sought to remedy this situation by containing “certain specialty-specific physical examinations,” which “favored more subspecialists.”This new specificity did contribute to the widespread conclusion that the E/M guidelines of 1997 are no less burdensome than their 1995 counterparts. And last year, the CMS announced it may pursue “comprehensive reform of E/M documentation guidelines.” But unless and until such reform occurs, the 1997 rules are in place—and you need to know how to use them to get properly compensated for your hard work.
  2. What is the difference between the 1995 and 1997 E/M Guidelines?
    The answer depends upon which aspect of the patient encounter you’re documenting:

    • History
      While the two sets of guidelines for documenting a history are the same, the 1997 rules specify physicians can get credit for taking an extended HPI by documenting four HPI elements, or by commenting on the status of three chronic or inactive conditions. If you document an extended HPI, you can code and bill at a higher level.
    • MDM
      The rules for documenting MDM are also the same under the 1995 and the 1997 guidelines. MDM level is always a function of the diagnoses and management options you consider, the amount and complexity of data you review, and the patient’s risk. The highest two of these three elements determines the MDM level in the encounter. The higher the MDM level, properly documented, the higher you code.
    • Exam
      As mentioned above, the biggest differences between the 1995 and 1997 guidelines revolve around the exam. In 1995, the rules included what Medical Economics called “a one-size-fit-all multi-system exam” of body areas and organ systems. But the 1997 rules add single organ system exams—cardiovascular; ear, nose and throat; eye; musculoskeletal; and others—that specialists find useful. When you accurately document the legitimate hard work you’re doing, you can claim the right amount of compensation using the optimal CPT® code.
  3. Which set of E/M rules am I supposed to use?
    Not all physicians welcomed the increased complexity of exam documentation under the 1997 rules. In fact, the AMA organized a “fly-in” of physicians to Chicago in 1998 to protest the new guidelines.Dr. Morton Field was one doctor who spoke at that event. He talked about having spent over an hour with a complicated patient just before leaving for Chicago. He said, to applause: “I wrote in my report, ‘Patient is stable.’ This is perfectly adequate for the general internist for whom I am doing the consulting work… I object to someone who wants me to… write like a third-year medical student.”

Because of such objections, CMS ultimately decided physicians may use the 1995 or the 1997 guidelines to document visits, based on whichever set of rules best suited their work and would prove more beneficial.

Two caveats are in order. You cannot “mix and match” the two sets of guidelines (for example, using one set to document the exam and the other to document the history.) And neither set of E/M Medicare guidelines covers surgeries, lab tests, preventive medicine, counseling, and imaging studies. All these services require adherence to their own documentation rules.

Find Out More With MDCodePro

Clearly, three questions and answers can’t exhaust all you need to know about the CMS E/M guidelines of 1997. To learn more, consider choosing MDCodePro as your online tool for medical coding training. You can use the app at your desktop computer or on your mobile device to access our video lecture series, in which Dr. Stemer guides you through the documentation requirements, using the 1997 guidelines, in an easy-to-follow, easy-to-remember way that equips you to code each visit for maximum accuracy, compliance, and compensation.

To get started, call us at 219-301-7265, or request information via our online form.

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