AMA CPT® Assistant - 2008 Issue 11 (November)

Evaluation and Management (E/M) Documentation Guidelines (November 2008)

November 2008 pages 3-4 Coding Communication:Evaluation and Management (E/M) Documentation Guidelines The American Medical Association (AMA) receives many questions regarding appropriate methods for documenting Evaluation and Management (E/M) services. The purpose of this article is to provide clarification concerning the role that the Centers for Medicare and Medicaid Services (CMS) (formerly known as Health Care Financing Administration [HCFA]) played in the development of the 1995 and 1997 Documentation Guidelines and CMS's subsequent use of these guidelines to establish documentation requirements for reporting E/M services. Background Information The 1995 Medicare Documentation Guidelines and the subsequent 1997 Guidelines were a continuation...

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