Can the 1995 and 1997 documentation guidelines be used simultaneously?

Using both the 1995 and 1997 documentation guidelines simultaneously is not permissible. Each set of guidelines provides distinct criteria for the documentation of Evaluation and Management (E/M) services. These criteria are designed to ensure consistency and accuracy in coding practices.

The 1995 guidelines focus primarily on the documentation requirements based on the medical history, examination, and medical decision-making involved in patient care, while the 1997 guidelines emphasize a more detailed assessment of the physical examination components. Mixing these guidelines can lead to confusion and inconsistencies in coding, as each guideline has its own specific rules for the level of service provided.

By adhering to either the 1995 or the 1997 guidelines exclusively for a given patient encounter ensures that coders and healthcare providers remain compliant with regulations and helps to maintain the integrity of coding practices. Therefore, it is essential to choose one guideline and apply it consistently throughout the documentation process for the encounter to accurately reflect the services rendered.