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The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However we will still need to use them when auditing notes from before 2023. 

This article does not apply to services performed after 1-1-2023.

Remember, don’t use the information in this article for current services.

Use these rules when billing for codes that use the 1995/1997 guidelines.

• You can use time to select Evaluation and management codes if typical time is listed for that code in the CPT® book and the visit is predominately counseling and coordination of care. Document the total time of the visit, the fact that more than 50% of the visit was counseling and the nature of the counseling.
• Emergency department visits do not have typical time listed, and time may not be used to select the level of ED visit. Three of the three components (history, exam and MDM) are required.

What codes continue to use 1995/1997 rules?

• Hospital services, 99221–99233
• Consultations, 99242–99255
• Home visits, 99341–99350
• Observation care, 99218–99220, 99224–99226,
• Observation or inpatient hospital care 99234–99236
• Domiciliary care, 99324–99337

Documentation requirements | Using time to select the code