What is a key distinction between the 1995 and 1997 documentation regarding exam definitions?

In the context of evaluation and management (E/M) coding, the year 1997 established guidelines that introduced a more rigorous structure for documentation compared to the earlier 1995 guidelines. The 1997 guidelines are known for requiring more specific elements in documentation, which include detailed levels of history, examination findings, and medical decision-making complexity. This greater specificity helps to ensure a higher standard of documentation accuracy and comprehensiveness, allowing providers to present a clearer clinical picture that correlates with the services performed.

The shift to requiring more specific documentation elements in the 1997 guidelines reflects an effort to enhance the quality of medical records and improve the consistency in coding across different providers and practices. This increased attention to detail is intended to support appropriate reimbursement and enhance the integrity of clinical documentation.