Documentation for Evaluation and Management (E/M) Services

March 26th, 2018

According to WPS, when billing or coding for E/M services you should follow a few guidelines.

Documentation must support the level of service billed and the medical necessity for the level billed. Below are additional tips for services which commonly incur CERT error findings for insufficient documentation.

Critical Care Visits 

Established patient office visit - CPT 99211 

Hospital Discharge Day Management 

Skilled Nursing Facility Care 

Subsequent Hospital Visits 

Please be aware that this list is not all inclusive. Providers should submit all documentation to support the medical necessity and level of service(s) billed in accordance with Medicare regulations and policies.


Documentation for Evaluation and Management (E/M) Services. (2018, March 26). Find-A-Code Articles. Retrieved from

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