Evaluation and Management Guidelines

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services




R




Evaluation and
Management Services Guide




December 2010 / ICN: 006764

,PREFACE



This guide is offered as a reference tool and does not replace content
found in the “1995 Documentation Guidelines for Evaluation and
Management Services” and the “1997 Documentation Guidelines for
Evaluation and Management Services.”
These publications are available in the Reference Section of this guide
and at http:// www.cms.gov/MLNProducts/Downloads/1995dg.pdf and
http://www.cms.gov/ MLNProducts/Downloads/MASTER1.pdf on the Centers
for Medicare & Medicaid Services website.

Note: Either version of the documentation guidelines, not a combination
of the two, may be used by the provider for a patient encounter.




This publication was current at the time it was published or uploaded onto the web. Medicare policy
changes frequently so links to the source documents have been provided within the document for your
reference. This publication is a general summary that explains certain aspects of the Medicare
Program; however, this is not a legal document and does not grant rights or impose obligations. The
Centers for Medicare & Medicaid Services (CMS) will not bear any responsibility or liability for the
results or consequences of using this summary guide. This document was current as of the date of
publication; nevertheless, we encourage readers to review the specific laws, regulations and rulings
for up-to-date detailed information. Providers are responsible for the correct submission of claims and
response to any remittance advice in accordance with current laws, regulations and standards.

CPT only copyright 2010 American Medical Association. All rights reserved. CPT is a registered
trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to
Government Use. Fee schedules, relative value units, conversion factors, and/or related components are
not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA

Evaluation and Management Services Guide 1

,does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no
liability for data contained or not contained herein.




Evaluation and Management Services

, TABLE OF CONTENTS
MEDICAL RECORD DOCUMENTATION........................................................................3


General Principles of Evaluation and Management Documentation.............3


Common Sets of Codes Used to Bill for Evaluation and Management Services 4


Evaluation and Management Service Providers...........................................6


EVALUATION AND MANAGEMENT BILLING AND CODING CONSIDERATIONS.......7


Selecting the Code That Best Represents the Service Furnished.................7


Other Considerations..................................................................................21


REFERENCE SECTION.................................................................................................22


Resources...................................................................................................22


“1995 Documentation Guidelines for Evaluation and Management Services” 23


“1997 Documentation Guidelines for Evaluation and Management Services” 39




Evaluation and Management Services Guide 3