Documentation Guidelines for Medical Decision Making

Margaret Maley, BSN, MS

Documentation Guidelines for Medical Decision Making – August 2017
by Margaret M. Maley, BSN, MS

With a brief history of their development
Thousands of pages of regulation have been generated since the American Medical Association (AMA) first introduced Evaluation and Management (E/M) codes to describe inpatient and outpatient visits in 1992. When originally published, the E/M code descriptors were ambiguous and unclear, resulting in the reporting of erroneous levels of service and the inability to audit or oversee the delivery of services to Medicare beneficiaries.

In 1995, the Centers for Medicare & Medicaid Services (CMS) revised the E/M guidelines to include more specific details about the patient history and the extent of the physical examination. That same year, the AMA and the Health Care Financing Administration (now CMS) introduced their collaboration on the development of E/M documentation guidelines. The AMA emphasized that guidelines were created for the following reasons:

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