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October 4, 2013

Documentation Guidelines for Evaluation & Management (E/M) Services: Reminder

The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) developed Evaluation & Management Documentation Guidelines to assist health care providers that submit claims to Medicare in documenting and correctly coding E/M services. There are two sets of guidelines, commonly known as the 1995 guidelines and 1997 guidelines. The following information was extracted from these guidelines and is a reminder about the intent of and principles behind documentation in patients’ medical records.

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

  • the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time;
  • communication and continuity of care among physicians and other healthcare professionals involved in the patient's care;
  • accurate and timely claims review and payment;
  • appropriate utilization review and quality of care evaluations; and
  • collection of data that may be useful for research and education

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

Documentation Principles

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

  1. The medical record should be complete and legible.
  2. The documentation of each patient encounter should include:
    1. reason for the encounter and relevant history,
    2. physical examination findings, and prior diagnostic test results;
    3. assessment, clinical impression, or diagnosis;
    4. plan for care; and
    5. date of the service and legible identity of the observer.
  3. Past and present diagnoses should be accessible to the treating and/or consulting physician.
  4. Appropriate health risk factors should be identified.
  5. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
  6. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record

Source: 1995 Documentation Guidelines for Evaluation and Management ServicesExternal PDF and 1997 Documentation Guidelines for Evaluation and Management ServicesExternal PDF

Additional Reminders from CGS

  • All documentation MUST be signed by the treating physician
  • The rationale for ordering diagnostic and other ancillary services MUST be noted in the patient’s chart.
  • Level of service is based on the care rendered, and not by volume of documentation.

Guidelines regarding signature requirements are located in the CMS Medicare Program Integrity Manual (Pub. 100-8), chapter 3, section, “Signature RequirementsExternal PDF.” Information is also available in CMS MLN Matters article MM6698External PDF, “Signature Requirements for Medical Review Purposes.”

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