AMA CPT® Assistant - 1995 Issue 1 (Spring)
About the Medicare Documentation Guidelines (Spring 1995)
Spring 1995 page 1 About the Medicare Documentation Guidelines These guidelines have been jointly developed by the American Medical Association and the Health Care Financing Administration. Our mutual goal is to provide physicians and claim reviewers 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 definition contained in CPT; would be widely accepted by clinicians and minimize any changes in record-keeping practices; and would be interpreted and applied uniformly by users across...
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Article Overview
This article explains the purpose and background of Medicare documentation guidelines developed by the AMA and HCFA, with emphasis on Evaluation and Management services. It is useful for physicians, coders, and claim reviewers who want context on documentation expectations, the role of CPT, and the general direction of Medicare review guidance in the mid-1990s.
Why This Topic Matters
Understanding the scope and intent of documentation guidance helps readers place Medicare review practices in context and recognize how guidance documents relate to Evaluation and Management documentation.
Article Sections
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Spring 1995 page 1
Introduces the documentation guidelines and explains their origin, purpose, and relationship to Evaluation and Management services. It also discusses the broader context in which the guidelines were released and how they were intended to be understood.
What You Will Learn
- The background and purpose of Medicare documentation guidelines
- How the guidelines relate to Evaluation and Management services
- The organizations involved in developing the guidance
- The general context in which the guidance was released
Who Should Read This
- Physicians
- Medical coders
- Claim reviewers
- Compliance and documentation staff
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