E/M Documentation Templates

In answer to many requests for assistance with the Medicare documentation requirements for Evaluation and Management (E/M) services, The ACOG Committee on Coding and Nomenclature has developed two templates that should make it easier for ob/gyns to comply with existing rules. One template complies with Medicare's 1995 guidelines and the other with their 1997 guidelines.

Medicare has stated that physicians will be held accountable for using either the 1995 or the 1997 guidelines, whichever is more advantageous to the physician. In making a choice, physicians should keep in mind the following:

1995 Guidelines

The history and medical decision-making criteria outlined in the 1995 guidelines are the same as the 1997 guidelines. The big difference in the guidelines is in the criteria for the examination. The 1995 criteria require less to be documented for the exam, but the exam criteria are vague and generally leave much to the opinion of the auditor, easily opening the door for differing opinion between auditor and physician. That is not to say that the physician may not eventually win an appeal, but it may mean that the physician has to appeal the results of an audit when opinions differ.

1997 Guidelines

The 1997 examination criteria are detailed and require more documentation. But the advantage is the 1997 criteria leave little room for auditor interpretation. It may be easier for auditors to verify that higher levels of service were correctly coded. While the 1997 criteria require some a little more time to learn, they are easily mapped using a template and once learned, many physicians have stated they prefer them to the old way of doing things.

Comments on the templates ACOG has developed should be directed to Savonne Montue at smontue@acog.org or by FAX to (202) 484-7480. We will keep you apprised of any changes in the documentation requirements.

You may download the 1995 and/or 1997 templates for documenting E/M services by clicking below.

Please click either here for the 1995 template or here for the 1997 template. You will be asked to save the disk to file. The files are in Microsoft Word format.

Contact:

Donna Tyler
Manager, Coding Education
dtyler@acog.org

Keisha Sutton
Coding Specialist
ksutton@acog.org