The documentation guidelines were designed by Medicare to define content of documentation for History, Physical Examination and Medical Decision Making. The Guidelines were initially developed and published in 1995 with general content requirements for each of the key elements of the Evaluation and Management levels. Subsequent to the initial format, CMS published the 1997 guidelines. This version divided documentation guidelines for the same three key elements but designed a point system for qualifying the level of physical examination which was based on each of the organ system examinations. Physicians were given the choice to use either the 1995 or 1997 guidelines but are free to select the version most favorable. In emergency medicine, the 1995 documentation guidelines are the most frequently used.
CMS has said that the guidelines are for Medicare only. Of course any other carrier may adopt whatever payment policy they choose. Many ED practices have implemented the Documentation Guidelines for all payers as they provide an objective means to determine the content of the Evaluation and Management level of service. As the CPT definitions are somewhat subjective, they provide less definition to the requirements for scoring the history, physical examination and medical decision making.
Yes, as long as there are specific references to individual elements that can be recognized according to those listed in the Documentation Guidelines. The physician is required to sign the completed template.
The official source for this information is the CMS web site at www.cms.hhs.gov. ACEP regularly monitors this site for changes. The 1995 and 1997 Documentation Guidelines can be found on the ACEP website.