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CMS to revise E&M Documentation Guidelines


Most physicians and other practitioners bill patient visits to the PFS under a relatively generic set of codes that distinguish level of complexity, site of care, and in some cases whether or not the patient is new or established. These codes are called Evaluation and Management (E/M) visit codes. Billing practitioners must maintain information in the medical record that documents that they have reported the appropriate level of E/M visit code. CMS maintains guidelines that specify the kind of information that is required to support Medicare payment for each level. There are three key components to selecting the appropriate level:
  • History of Present Illness (History)
  • Physical Examination (Exam) and
  • Medical Decision Making (MDM). 
CMS agreed with continued feedback from stakeholders that these guidelines are potentially outdated and need to be revised, especially the history and exam components.

CMS is seeking comment from stakeholders on specific changes they should undertake to update the guidelines, to reduce the associated burden, and to better align E/M coding and documentation with the current practice of medicine.

Comments on the CMS proposal to revise the E/M documentation guidelines are due no later than Sept. 11, and can be submitted by one of four methods:

1. Submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”

2. Mail written comments to:

CMS-1676-P 2
Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
P.O. Box 8016
Baltimore, MD 21244-8013.

3. By express or overnight mail. You may send written comments to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850.

4. Deliver (by hand or courier) written comments before the close of the comment period to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW., Washington, DC 20201

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