Memorandum from Department of Health & Human Services, 
Health Care Financing Administration

Date:		June 30, 1997

From:		Acting Director
		Office of Benefits Integrity, BPO
Subject:	Documentation Guidelines for Evaluation and Management Services 
for Physician Services 

- ACTION

To:		All Associate Regional Administrators for Medicare


This memorandum 
concerns the latest revisions to the Documentation Guidelines for Evaluation and 
Management Services.  The changes and additions include the following:


-	the content of general multi-system examinations had been defined with greater 
clinical specificity


-	documentation requirements for general multi-system examinations have been 
changed



-	content and documentation requirements have been defined for examinations 
pertaining to ten organ systems



-	several editorial changes have been made in the definition of the four types of 
exams



-	the definition of an extended history of present illness has been expanded to 
include chronic or inactive conditions.


Please send the attached guidelines to all Contractors (both intermediaries and carriers) in 
your regions.  Instruct contractors to inform providers in their next bulletin that these 
guidelines are available on the American Medical Association (AMA) bulletin board, the 
HCFA Web page and through the specialty societies.  Encourage contractors to publish 
these guidelines if possible.  These guidelines are not subject to the AMA copyright rules.  
The bulletins should also inform physicians that if they are unable to obtain these 
guidelines through these means the guidelines can be obtained from the contractor.

While 
these guidelines will be effective October 1, 1997, contractors should also inform 
providers that there will be a grace period between October 1, 1997 and January 1, 1998 
during which providers can document Evaluation and Management services in accordance 
with the current guidelines or the revised ones.

The AMA and specialty societies will be 
working cooperatively to facilitate training.  Instruct contractors to continue working with 
the specialty societies in educating the provider community.  However, contractors may 
provide training on an "as needed basis."


Remind contractors of the following:


-	the documentation guidelines developed jointly by HCFA and the AMA represent 
HCFA policy regarding interpretation of the E/M codes in CPT and the medical record 
documentation that is required to support a given level of code.  The documentation 
guidelines are considered instructional material from HCFA.


-	reviewers must request all material in the medical record which would support the 
level of service reported.  This includes not only the progress note itself but such things as 
separate order sheets for tests, patient completed history forms, etc.


-	reviewers must look through the entire record they receive and "give credit" for 
whatever they can find, regardless of how the record is organized.



-	corrective action may include requiring additional documentation, beyond that 
indicated in the documentation guidelines.  If, for example, a carrier concludes a physician 
is abusing the rules on documenting and reporting encounters dominated by counseling, 
documentation of the time spent counseling as well as the total time may be required.

If 
you or your staff have any questions, please contact Linda Easter, of my staff at (410) 
786-6978.


	Marjorie Kanof, M.D.

Memorandum from Department of Health & Human Services, 
Health Care Financing Administration