AMA CPT® Assistant - 1995 Issue 1 (Spring)
Documentation Guidelines for Evaluation and Management Services (Spring 1995)
Spring 1995 pages 2-8 Documentation Guidelines for Evaluation and Management Services Foreword These guidelines have been jointly developed by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA). Our mutual goal is to provide physicians and claims reviews with advice about preparing or reviewing documentation for Evaluation and Management services. In developing and testing the validity of these guidelines, special emphasis was placed on assuring that they: are consistent with the clinical descriptors and definitions contained in CPT; would be widely accepted by clinicians and minimize any changes in record-keeping practices; and would be interpreted and...
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Article Overview
This article explains the documentation framework used for evaluation and management services and describes the major components of a medical record that support those services. It is aimed at physicians, coders, and claims reviewers who need to understand how documentation is organized and evaluated, including guidance tied to CPT and ICD-9-CM reporting. The content addresses general documentation principles, history, examination, medical decision making, risk, and time-based counseling or coordination-of-care encounters.
Why This Topic Matters
Clear documentation is central to accurate claims review, consistent evaluation and management reporting, and communication among clinicians and payers. This article helps readers understand the structure and expectations behind those records.
Article Sections
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Foreword
Introduces the purpose of the guidelines and the organizations involved in developing them. It also frames the article as a documentation resource for evaluation and management services.
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I. Introduction
Explains why medical record documentation matters and what payers may request when reviewing claims. The section provides context for the documentation standards that follow.
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II. General Principles of Medical Record Documentation
Summarizes broad documentation principles that apply across medical and surgical services. It covers record completeness, legibility, and the relationship between chart documentation and reported services.
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III. Documentation of E/M Services
Describes the main documentation framework for evaluation and management services and the key components used in assessment. The section also notes service categories and the role of time in certain encounters.
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A. Documentation of History
Outlines the history component of evaluation and management documentation and the major elements used to characterize it. It also addresses variations for different patient groups and encounter types.
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Chief Complaint (CC)
Defines the role of the chief complaint within the history component. It emphasizes that the reason for the encounter should be documented.
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History of Present Illness (HPI)
Discusses the structure of the present illness narrative and the kinds of information that may appear in it. It distinguishes brief and extended histories.
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Review of Systems (ROS)
Describes the review of systems as a body-system inventory and explains how different levels of review are documented. It also notes system groupings used in this context.
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Past, Family and/or Social History (PFSH)
Explains the three areas included in past, family, and social history and how they relate to different E/M categories. It addresses pertinent and complete history review.
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B. Documentation of Examination
Presents the framework for documenting the physical examination portion of E/M services. It distinguishes exam types and the body-area and organ-system perspectives used in the guidelines.
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C. Documentation of the Complexity of Medical Decision making
Describes how the complexity of medical decision making is assessed for E/M documentation. The section addresses diagnoses, data review, and risk as the main factors.
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Number of Diagnoses or Management Options
Discusses how the scope of potential diagnoses and management choices contributes to complexity assessment. It also references documentation of assessment and management changes.
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Amount and/or Complexity of Data to Be Reviewed
Covers the types of information review that may affect decision-making complexity. It includes discussion of tests, records, and information from sources other than the patient.
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Table of Risk
Presents a risk framework used in evaluating E/M services, organized by general levels of risk. It also links risk to presenting problems, diagnostic procedures, and management options.
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Risk of Significant Complications, Morbidity, and/or Mortality
Explains how overall risk is considered within E/M documentation. The section focuses on the relationship between patient factors, procedures, and management choices.
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D. Documentation of an Encounter Dominated by Counseling or Coordination of Care
Addresses encounters in which counseling or coordination of care is the predominant activity. It explains how time-related documentation fits into the E/M framework.
What You Will Learn
- How evaluation and management documentation is organized into major components
- What broad elements are expected in medical record documentation
- How history, examination, and medical decision making are presented in the guidelines
- How risk and data review factor into documentation assessment
- How time-based documentation is addressed for counseling or coordination-of-care encounters
Who Should Read This
- Physicians
- Medical coders
- Claims reviewers
- Billing staff
- Compliance professionals
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