A Primer on the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services
After a recent post discussing preparation and maintenance of medical records, I received several requests for further information regarding the 1995 and 1997 Documentation Guidelines for Evaluation and Management (“E/M”) Services that I briefly discussed.
The 1995 guidelines are applicable to: (a) all medical and surgical services and (b) in all settings. The 1997 guidelines, in addition to incorporating the 1995 guidelines, focus on specialists and outline each component of a typical E/M service. The following is an outline of the general principles that health care practices must adhere to when structuring medical records in accordance with the 1995 and 1997 guidelines.
- The medical record should be complete and legible.
- The documentation of each patient encounter should include:
· reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
· assessment, clinical impression or diagnosis;
· plan for care; and
· date and legible identity of the observer.
- If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
- Past and present diagnoses should be accessible to the treating and/or consulting physician.
- Appropriate health risk factors should be identified.
- The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
- 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.
The CMS website has further information regarding the 1995 (pdf) and 1997 (pdf) guidelines.
