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...
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Article Overview
This article reviews the background and purpose of Evaluation and Management documentation guidance and explains how CMS-developed documentation guidelines relate to CPT E/M coding. It is aimed at physicians, coders, compliance staff, and others who need to understand the distinctions among AMA CPT materials, CMS documentation standards, and third-party payer practices. The piece also covers broader trends in E/M code distribution, the role of electronic documentation systems, and the continuing importance of physician review and documentation support.
Why This Topic Matters
Understanding the distinction between CPT E/M code selection guidance and CMS documentation guidelines helps organizations align documentation practices with payer expectations and reduce coding and compliance risk. The article is relevant to those managing E/M documentation, auditing, payer policy review, and electronic record workflows.
Article Sections
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Background Information
Introduces the historical context for the documentation guidelines and the role of federal and professional organizations in their development.
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The Evaluation and Management Codes
Explains how CPT E/M coding guidance differs from CMS documentation guidance and describes the general structure of E/M services in CPT materials.
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The CMS Documentation Guidelines
Summarizes how the CMS documentation guidelines were developed, their relationship to the CPT framework, and their general structure.
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Use of the 1995 and 1997 Documentation Guidelines by Non-Medicare Payers
Discusses how third-party payers may use documentation standards and the importance of payer-specific guidance.
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Trends
Reviews broader patterns in E/M code distribution and considerations related to electronic documentation and code selection systems.
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Conclusion
Summarizes the continuing importance of physician review, documentation support, and attention to applicable guidance when reporting E/M services.
What You Will Learn
- How CMS documentation guidelines relate to CPT E/M coding guidance
- What historical factors shaped the development of E/M documentation standards
- How payer-specific documentation policies can differ from CMS guidance
- Why electronic documentation systems can affect E/M coding workflows
- What responsibilities remain with the physician when reporting E/M services
Who Should Read This
- Physicians
- Medical coders
- Coding auditors
- Compliance staff
- Practice managers
- Revenue cycle professionals
- Health information management professionals
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