What are E&M Services?
Not all medical services are covered under the 1995 E&M Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.
What are the differences between the 1995 and 1997 E&M Guidelines?
The 1995 E&M Guidelines issued by CMS were the first medical documentation guidelines for E&M services. The 1995 Guidelines use “body areas” instead of “organ systems” for the physical exam and do not include organ system specific exam types. The 1997 E&M guidelines expanded and clarified areas of uncertainty in the documentation rules. CMS states you can use either the 1995 or 1997 E&M Guidelines for medical documentation.
What needs to be documented for E&M services?
The 1995 E&M Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.
Documentation Components from the 1995 E&M Guidelines:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
Medical Decision Making (MDM)
- The number of diagnosis or management options
- Amount and complexity of medical data reviewed
- Risk of significant complications, morbidity, or mortality