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What is the difference between 1995 and 1997 versions of Evaluation and Management services


There are two versions of the documentation guidelines – the 1995 version and the 1997 version. The most substantial differences between the two versions occur in the examination documentation section. Either version of the documentation guidelines, not a combination of the two, may be used by the provider for a patient encounter.

The 1997 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit: General multi-system examination and Single organ examination. A general multi-system examination involves the examination of one or more organ systems or body areas

The 1995 documentation guidelines state that the medical record for a general multi-system examination should include findings about eight or more organ systems.

An extended HPI:

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.

Some important points that should be kept in mind when documenting general multi-system and single organ system examinations (in both the 1995 and the 1997 documentation guidelines) are:

Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is not sufficient.

Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

Reference:


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