Documentation Guidelines FAQ

FAQ 1. What are the Documentation Guidelines?

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.

FAQ 2. Do the Documentation Guidelines apply only to Medicare, or to Medicaid and CHAMPUS as well?

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.

FAQ 3. Can templates be used for satisfying the Documentation Guidelines? 

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.

FAQ 4. How can I get a copy of the CMS Documentation Guidelines?

The official source for this information is the CMS  web site at  ACEP regularly monitors this site for changes.  The 1995 and 1997 Documentation Guidelines can be found on the ACEP website.


The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or

Updated 04/2014

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