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Documentation Guidelines for Evaluation and Management (E/M) Services

The Medicare Learning Network

The Medicare Learning Network® (MLN) Educational Web Guides Documentation Guidelines for Evaluation and Management (E/M) Services page offers health care professionals E/M services information and resources. The following E/M publications can be accessed in the "Downloads" Section below:

  • Evaluation and Management Services Guide (November 2014) – This guide is designed to provide education on evaluation and management services. It includes the following information: medical record documentation, evaluation and management billing and coding considerations, the "1995 Documentation Guidelines for Evaluation and Management Services" and the "1997 Documentation Guidelines for Evaluation and Management Services."
  • 1995 Documentation Guidelines for Evaluation and Management Services.
  • 1997 Documentation Guidelines for Evaluation and Management Services.

E/M services health care professionals may use either version of the 1995 or 1997 documentation guidelines, not a combination of the two, for a patient encounter.  An FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services is available in the Downloads Section below. It provides information about using the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an E/M service performed on or after September 10, 2013.

If you would like to contact the MLN, please email us at MLN@cms.hhs.gov.