The official 1997 E&M Guidelnes issued by CMS

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

• HGSA Documentation worksheet
• 1997 Documentation Guidelines for Evaluation and Management Services
• 1995 Documentation Guidelines for Evaluation and Management Services