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E&M Guidelines: Do I use 1995 or 97?

Evaluation and Management Guidelines Which One of the Two Sets of Rules Do I Use – 1995 or 1997?

In addition to the guidelines found in your CPT (Current Procedural Terminology Manual), CMS (formerly HCFA – Health Care Financing Administration) has published two sets of documentation guidelines. The first became effective in 1995 and  the second version in 1997.  The goal was to develop,  and then to refine, a set of quantifying mechanics to score the level of medical service.  The guidelines specifically identify the elements that must be documented in the medical record to support a level of service, as well as a methodology to determine the level of medical decision making.

The attempt to implement the 1997 rules was not a smooth one, and CMS (formerly HCFA) relented, stating that until they formally adopt a replacement,  either set of rules- (’95 or ’97) may be used.  The principal difference is the exam portion –  1997 has a series of detailed examinations with required items indicated by shaded areas or bullets, while the 1995 rules have a more general counting of body areas and systems.  You may choose either the 1995 or 1997 rules.

In order to accurately document an E&M encounter and to choose effectively between the two guidelines, you must know both.   Both can be found on the CMS web site –  or our web site –

These rules are long and complex, and the combined material is about 67 printed pages. Appropriate supporting E/M documentation is a targeted area by Federal investigators and a pattern of coding errors or failure to support a level of care may carry civil and criminal penalties. It is important to get E/M documentation right the first time.

You may find a dictation template customized for your specialty very helpful.  The Compliance Office has already assisted several departments in their development of such tools, and we would be happy to help you.  Or if you would like to have an E/M instruction presentation in your department – just give us a call.

 If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at


Webmaster, College of Medicine, Office of Physician Billing Compliance
Page created 9/31/99. Reviewed December 2014.

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