AMA CPT® Assistant - 1997 Issue 7 (July)
Revised Documentation Guidelines for Evaluation and Management Services (July 1997)
July 1997 page 1-end Revised Documentation Guidelines for Evaluation and Management Services This is the most recent update of the Medicare Documentation Guidelines that were originally published in the winter of 1995. These newly revised guidelines are a continuation of the work that was begun in February 1988 with the preparation for the revision of the Evaluation and Management codes that were published in 1992. From the medical perspective, documentation guidelines may seem inconsequential when compared with the many complex and difficult patient care issues facing Medicare today. It is clear, however, that the issue of documentation will remain...
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Article Overview
This July 1997 article explains the revised Medicare documentation guidelines for evaluation and management services and describes how the guidance was developed by the AMA and HCFA. It covers the general principles of medical record documentation, the key components used in E/M service support, specialty-based examination tables, and the overall framework for assessing medical decision making and time-based encounters. The article is relevant to physicians, coders, auditors, and other staff involved in E/M record review and claims support.
Why This Topic Matters
The guidance affects how E/M encounters are documented for Medicare review and helps readers understand the documentation structure used to support service reporting and audit readiness. It is important for anyone who prepares, reviews, or audits medical records tied to E/M services.
Article Sections
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July 1997 page 1-end
Introductory publication information and context for the revised documentation guidance.
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Foreword
Background on the development of the revised guidelines and the organizations involved in producing them.
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I. Introduction
Overview of why medical record documentation matters and how payers use documentation in review processes.
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II. General Principles of Medical Record Documentation
Broad principles for maintaining complete, legible, and supportable medical records across settings.
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III. Documentation of E/M Services
Core documentation framework for evaluation and management services, including the key components and special considerations for different patient groups.
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A. Documentation of History
General history documentation concepts, the major history elements, and related documentation guidance.
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B. Documentation of Examination
Overview of examination types and the structure used to describe system- and organ-based exam requirements.
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General Multi-System Examinations
Multi-system examination structure and the documentation expectations associated with different exam levels.
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Single Organ System Examinations
Single organ system examination categories and the level-based documentation framework used for them.
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Table 1-Elements Required for Each Type of History
Tabular summary of history types and the elements associated with each history level.
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Table 2-General Multi-System Examination
Detailed multi-system examination content organized by body area and system.
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Table 3-Cardiovascular Examination
Specialty-focused cardiovascular examination content and level-based documentation expectations.
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Table 4-Ear, Nose, and Throat Examination
Specialty-focused ear, nose, and throat examination content and level-based documentation expectations.
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Table 5-Eye Examination
Specialty-focused eye examination content and level-based documentation expectations.
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Table 6-Genitourinary Examination
Specialty-focused genitourinary examination content and level-based documentation expectations.
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Table 7-Hematologic/Lymphatic/Immunologic Examination
Specialty-focused hematologic, lymphatic, and immunologic examination content and level-based documentation expectations.
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Table 8-Musculoskeletal Examination
Specialty-focused musculoskeletal examination content and level-based documentation expectations.
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Table 9 - Neurological Examination
Specialty-focused neurological examination content and level-based documentation expectations.
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Table 10-Psychiatric Examination
Specialty-focused psychiatric examination content and level-based documentation expectations.
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Table 11-Respiratory Examination
Specialty-focused respiratory examination content and level-based documentation expectations.
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Table 12-Skin Examination
Specialty-focused skin examination content and level-based documentation expectations.
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C. Documentation of the Complexity of Medical Decision Making
Framework for assessing the complexity of decision making in E/M services, including data review and risk.
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Table 13-Elements of Medical Decision Making
Tabular summary of the components used to classify medical decision making complexity.
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Table 14-Table of Risk
Risk framework used in medical decision making, organized by level and broad clinical categories.
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D. Documentation of an Encounter Dominated by Counseling or Coordination of Care
Guidance for encounters in which counseling or coordination of care is the main factor in selecting the service level.
What You Will Learn
- How the revised Medicare documentation guidelines are organized for E/M services
- Which broad documentation elements are emphasized for history, examination, and medical decision making
- How the guidance addresses multi-system and single organ system examinations
- What kinds of risk and data review considerations are part of E/M documentation support
- How counseling- or coordination-dominated encounters are documented at a high level
Who Should Read This
- Physicians
- Medical coders
- Medical auditors
- Practice managers
- Compliance staff
- Billing staff
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