Forward

FOREWORD

These guidelines have been developed jointly by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA).  Our mutual goal is to provide physicians and claims reviewers with advice about preparing or reviewing documentation for Evaluation and Management services.  In developing and testing the validity of these guidelines, special emphasis was placed on assuring that they:

•          are consistent with the clinical descriptors and definitions contained in CPT,

•          would be widely accepted by clinicians and minimize any changes in record-keeping practices, and

•          would be interpreted and applied uniformly by users across the country.

This edition contains a substantial amount of new material and a number of significant revisions in material that appeared in the first edition.  Because of the extensive changes, the section on examination which begins on page 10 should be read in its entirety.  In this edition:

•          The content of general multi-system examinations has been defined with greater clinical specificity.

•            Documentation requirements for general multi-system examinations have been changed.

•          For the first time, content and documentation requirements have been defined for examinations pertaining to ten organ systems.  The content of these examinations was developed with the assistance of representatives from the specialties that frequently perform these examinations.

•          Several editorial changes have been made in the definitions of the four types of examinations at the top of page 10.  This text also appears in CPT itself  in the section headed “Evaluation and Management (E/M) Services Guidelines,” but the revisions will not appear there until the 1999 edition of CPT.

•          The definition of an extended history of present illness on page 7 has been  expanded to include information about chronic or inactive conditions.

The AMA and HCFA wish to thank the CPT Editorial Panel, the CPT Advisory Committees, the Practicing Physicians Advisory Council, and the Medicare Contractor Medical Directors for their thoughtful advice, comments and direction concerning the many complex issues that were addressed in the development of these guidelines.  The AMA and HCFA are committed to continually improving these guidelines and welcome comments based on their usage.