Reimbursement Advisor

Making the most of Medicare’s guidelines


Q I recently discovered that a nearby practice is using both the 1995 and 1997 Medicare guidelines for coding. However, it is my understanding that you have to choose one set or the other and use it exclusively. Our office uses the 1995 guidelines, and our audit form reflects that decision. Which strategy is correct?

A Both approaches are correct. According to Medicare, you are free to use either set of guidelines or take advantage of both. For example, you may change sets from one patient to the next. If you are audited by Medicare, the auditor will select the set that gives your practice the advantage and will not ask which set you utilized.

This rule was never officially included in the Medicare regulations. However, it was communicated to the former AMA president Percy Wooten, MD, by Nancy-Ann Min DeParle of the Health Care Financing Administration (HCFA). In April, 1998, she said: “I am directing carriers to continue to use both the 1995 and 1997 guidelines, whichever is more advantageous to the physician, until the revisions [to the guidelines] have been completed and there has been an adequate period of time for testing and education.”

Feel free to continue using only the 1995 guidelines. Actually the only difference between the 2 sets is the physical examination criteria.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Next Article: