decisionhealth Newsletters, Answer Books - 2008 Issue 12 (December)
Answer_Book / Documentation_Guidelines_for_EM_Services / o
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Article Overview
This article explains the documentation guidelines used for evaluation and management services and summarizes how CMS and the AMA developed and revised the guidance. It is relevant to physicians, auditors, and coding professionals who need to understand the documentation framework, the relationship to CPT, and the general areas where the 1997 edition introduced updates.
Why This Topic Matters
Accurate documentation guidance affects E/M auditing, compliance review, and record-keeping practices. Knowing which guideline version applies and how the material is organized helps clinicians and coders interpret documentation expectations consistently.
What You Will Learn
- How CMS and the AMA framed documentation guidance for E/M services
- Why the 1995 and 1997 guideline versions are both referenced
- What broad categories of documentation content were revised in the 1997 edition
- How the guidelines relate to CPT-based clinical descriptors and definitions
Who Should Read This
- Physicians
- Medical coders
- Auditors
- Compliance staff
- Claims reviewers
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