We hope these articles from Family Practice Management will help you to comply with the documentation guidelines for E/M services. Medicare carriers base their medical reviews on the 1994 or 1997 version of the guidelines, "whichever is most advantageous to the physician," according to the Centers for Medicare & Medicaid Services (CMS).
The articles that were published in FPM in early 1995 explain the version of the guidelines that was introduced in November 1994 and enforced beginning in August 1995.
The articles that were published in FPM in late 1997 and early 1998 explain the version of the guidelines that was released in 1997 and originally scheduled for implementation on Jan. 1, 1998. This version, which overhauled the guidelines for exam documentation, defined clinically specific content and documentation requirements for 11 types of exams. Since this version of the guidelines left the 1994 guidelines for documentation of history and medical decision making relatively untouched, we did not devote new articles to these areas.
The AMA's CPT Editorial Panel is attempting to overhaul the E/M codes. A hope in revising the E/M codes is that documentation guidelines would no longer be necessary, but there is no guarantee of that. When or if either the codes or the documentation guidelines change, FPM will do its best to educate you.
Articles on Medicare's E/M Documentation Guidelines
Articles
Don't Read This Article!
-- (Documenting History) (Family Practice Management - February 1995)
Exam Documentation: Charting Within the Guidelines
-- (Family Practice Management - March 1995)
Thinking on Paper: Guidelines for Documenting Medical Decision Making
-- (Family Practice Management - April 1995)
A Documentation Toolbox
-- (Family Practice Management - May 1995)
Exam Documentation Just Got Harder
-- (Family Practice Management - March 1995)
Three Documentation Tools That Work
-- (Family Practice Management - January 1998)
An Update on the E/M Codes and Documentation Guidelines
-- (May 2003 -- Family Practice Management)
Other resources
The original Pocket Guide to the Documentation Guidelines was published in the May 1995 issue of FPM. The 1997 pocket guide was published in the January 1998 issue of FPM and again in the October 2003 issue. Individual copies of the 1995 and 1997 pocket guides may be purchased through the AAFP Order Department (800-944-0000). Ask for item number 556 for the 1995 pocket guide and item 557 for the 1997 pocket guide. The pocket guide is not available on the Web due to its format.
The Documentation Guidelines may be downloaded from the CMS web site (http://www.cms.hhs.gov/MedlearnProducts/20_DocGuide.asp) or you may ask your carrier to send you a copy.
The Documentation Guidelines may be downloaded from the CMS web site (http://www.cms.hhs.gov/MedlearnProducts/20_DocGuide.asp) or you may ask your carrier to send you a copy.
