There are two versions of the documentation guidelines – the 1995 version and the 1997 version. The most substantial difference between 95 and 97 guidelines 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.
1995 E/M Guidelines
The 1995 documentation guidelines state that the medical record for a general multi-system examination should include findings about eight or more organ systems.
The 1995 E/M guidelines should describe four or more elements of the present HPI or associated comorbidities.
1997 E/M Guidelines
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 1997 E/M guidelines should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions.
Coding Guidelines For Documenting General Multi System Examinations (1995 & 1997)
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).