What is one of the most significant differences between the 1995 and 1997 documentation guidelines?

One of the most significant differences between the 1995 and 1997 documentation guidelines lies in the examination criteria. The 1997 guidelines introduced a more detailed and specific approach to the components of the physical examination. While both guidelines established frameworks for the documentation of evaluation and management (E/M) services, the 1997 guidelines differentiated between the levels of examination required based on the type of service being provided, categorizing them into various types such as "Expanded Problem Focused," "Detailed," and "Comprehensive."

These distinctions in the examination criteria ultimately aimed to enhance the clarity and accuracy of the documentation required for billing, allowing for better categorization of services based on the complexity and extent of the examination performed. This improved structure helps ensure that the documentation accurately reflects the service provided, aligning with the physician's decision-making process and justifying the coding used.

Thus, understanding these differences is crucial for proper medical auditing and coding practices, ensuring compliance with regulatory standards while safeguarding against potential audit risks.