It is essential that you use the CMS Documentation Guidelines for Evaluation and Management services while coding for a claim that you will submit to Medicaid (depending upon the state) and / or Medicare. Several groups prefer to follow CMS 'guidelines across the board for every payers. Others Follow CMS guidelines for Medicare and other governmental payers and apply CPT rules for all other patients.
Remember that for other payers, which guidelines you use will most likely hinge on whether you participate with the payer or not. In case you participate, you are required to use the payer's chosen guidelines and stay in compliance with associated payer policies. In case you do not participate with a payer, then generally the CPT guidelines are relevant.
CPT rules are normally less numerically concrete and permit the clinician some freedom based on the medical necessity of the specific clinical encounter. CMS is compiled to officially inform providers of its changes to CPT requirements; in the absence of such particular notifications CPT requirements are understood to be in effect for Medicare patients. For CPT EM codes, CMS requests their carriers to audit charts by either CMS '1995 guidelines or their 1997 guidelines, whichever is most beneficial to the physician. Mostly, emergency medicine groups go with 1997 guidelines.
The 1995 CMS guidelines were issued as a joint effort between the AMA and HCFA (now CMS) to help physicians comprehend the CMS guidelines in context with the AMA's Current Procedural Terminology (CPT) coding system.
Evaluation and Management (E / M) service guidelines contain seven components which are history, exam, medical decisions making, time, coordination of care, nature of presenting problem, and counseling. The first three are key components which are used in selecting the correct E / M service code. The CMS and CPT history components are the same.
History documentation covers the history of present illness or HPI, review of systems or ROS as well as past medical, family, and social history or PMFS. These particular elements may be documented independently or contained within one statement.
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