Description

This is a concise review of the medical documentation requirements for evaluation and management services. This medical documentation summary targets all health care providers who must document inpatient or outpatient health care encounter information for billing and coding for third party payers. Outlined in this summary is the 1997 Guidelines for Evaluation & Management Services published by Medicare. The individual documentation requirements for the history, examination and medical decision making components of medical documentation are illustrated through the use of Medicare's auditing tool, CMS' Medicare Part B HGSAdministrators Documentation Worksheet.