Codes and Documentation for Evaluation and Management …

294 Codes and Documentation for Evaluation and Management ServicesThe Evaluation and Management (E/M) Codes were introduced in the 1992 up-date to the fourth edition of Physicians Current Procedural Terminology (CPT).These Codes cover a broad range of services for patients in both inpatient andoutpatient settings. In 1995 and again in 1997, the health Care Financing Ad-ministration (now the Centers for Medicare and Medicaid services , or CMS)published Documentation guidelines to support the selection of appropriateE/M Codes for services provided to Medicare beneficiaries. The major differ-ence between the two sets of guidelines is that the 1997 set includes a single-sys-tem psychiatry examination ( mental status examination) that can be fullysubstituted for the comprehensive, multisystem physical examination requiredby the 1995 guideline. Because of this, it clearly makes the most sense formental health practitioners to use the 1997 guidelines (see Appendix E).

E/M services, although for mental health providers the 1997 version is the obvi-ous choice. The E/M codes are generic in the sense that they are intended to be used by ... ordination of care.) • The 1995 and 1997 CMS documentation guidelines for E/M codes have be-

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