Evaluation & Management (E/M) Services - Proper Documentation

Proper documentation of your Evaluation and Management (E/M) Services is crucial when submitting claims to Medicare for your practice.

A short fact sheet was produced in April 2011 by the "Department of Health And Human Services - CMS" on proper E/M documentation. Topics addressed on this fact sheet include:

• Components of an Evaluation and Management (E/M) Service
• Tips on Documentation: ‘If It Wasn't Documented, It Wasn’t Done!’
• Determining the Correct Level of Code
• Links to Resources for: "1995 Documentation Guidelines for Evaluation and Management Services” and “1997 Documentation Guidelines for Evaluation and Management Services"

To download and view the full E/M documentation fact sheet published by the Department of Health And Human Services - Centers for Medicare & Medicaid Services, please go to the following link: Evaluation and Management (E/M) Services: Complying with Documentation Requirements