Appendix C - 1995 EM Guidelines / Overview

Why This Topic Matters

Understanding the 1995 E/M guidelines helps readers interpret documentation expectations across common service settings and recognize how the framework differs when counseling or coordination of care predominates or when documentation varies by patient population.

Article Sections

1. Overview of the 1995 E/M guidelines

   Introduces the guideline framework and the service settings where the documentation approach is applied. It also notes where to refer for the full CPT descriptors and selection instructions.

2. Core documentation components

   Describes the broad components used in defining levels of evaluation and management services. The section identifies the major elements that make up the documentation framework.

3. Special considerations for certain patient groups

   Explains that documentation may vary for infants, children, adolescents, pregnant women, and newborns. It addresses how records can differ across history and examination areas for these populations.