E/M Weekly Tip: General Documentation

When billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.

For more information please review FAQ on 1995 & 1997 Documentation Guidelines for Evaluation and Management Services (PDF, 29 KB).