There are two sets of E/M documentation guidelines. In 1995, CMS released the first set of guidelines that were tailored more towards primary care. The specialists soon spoke up, stating that under the 1995 guidelines, system-focused examinations were under-represented. Responding to the dissatisfaction, CMS created a new set of guidelines in 1997 designed for specialists.
In addition to the vast differences in examination guidelines, there is one other unique difference between the two sets of guidelines. In documenting the history of present illness (HPI) for a patient, the 1995 Guidelines stated that four elements of HPI (a total of eight to choose from) were needed to justify either a detailed or comprehensive level of service. For the 1997 Guidelines, providers have the choice of either four elements of HPI or the status of three chronic conditions. Again, these are the only real differences between the two sets of guidelines.
WPS, the Medicare Part B Legacy Carrier for four states in the Midwest, sent an e-mail blast out last month stating that “based on a communication received from CMS several years ago”, WPS was incorrectly applying the standard of the status of three chronic conditions to providers who used the 1995 guidelines. Unfortunately for providers, the CERT contractor was not privy to the same communication, and was correctly applying the guidelines as written. WPS went on in the e-mail to state that beginning with all dates of service on or after April 19th, the status of three chronic conditions for HPI will be applied only to documentation utilizing the 1997 guidelines.
The upshot of this is that providers who have for years believed, based on guidance from CMS interpreted by WPS, that their documentation was correct, may have been receiving CERT errors and been responsible for overpayments because two independent contractors were being given conflicting information and guidance from CMS. It took too long to figure this out.