The official 1995 E&M Guidelines from CMS

Download the 1995 E&M Guidelines issued by Medicare as a PDF

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:

Medical History

  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Past Family and Social History (PFSH)
  • Review of Systems (ROS)

Physical Exam

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

References for the 1995 E&M Guidelines

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