Medicare adds flexibility to E/M documentation guidelines

The Centers for Medicare & Medicaid Services (CMS) recently added a small measure of flexibility to the documentation guidelines for evaluation and management services.

Historically, CMS has required physicians to choose either the 1995 or 1997 version of the guidelines when documenting a given encounter. That has sometimes left family physicians in a quandary. Many prefer the simplicity of the exam portion of the 1995 guidelines over the “bullet points” in the exam portion of the 1997 guidelines. But they also like the history portion of the 1997 guidelines, which reference “the status of at least three chronic or inactive conditions” in the definition of an extended History of Present Illness – something missing from the 1995 guidelines.

CMS has acknowledged the problem, recently adding the following to its frequently asked questions on the documentation guidelines:

Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?

A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service [emphasis added].

It is a small change on the part of CMS, but hopefully, it is one that will allow family physicians and others to enjoy the best of both sets of documentation guidelines.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians