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

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

• Evaluation and Services Fact Sheet – This fact sheet describes common Comprehensive Error Rate Testing (CERT) Program errors related to E/M services and provides information on the documentation needed to support a claim submitted to Medicare for E/M services.
• Evaluation and Management Services Guide (December 2010) – 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 providers may use either version of the documentation guidelines, not a combination of the two, for a patient encounter.

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