The official 1997 E&M Guidelnes issued by CMS

1997 EM Guideliness

Download your PDF copy of the 1997 E&M Guidelines

What are E&M Services?

  Not all medical services are covered under the 1997 E&M Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.

What needs to be documented for E&M services?

The 1997 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 1997 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 1997 E&M Guidelines

Comment is closed.