Documentation Guidelines for Medical Decision Making

With a brief history of their development
Thousands of pages of regulation have been generated since the American Medical Association (AMA) first introduced Evaluation and Management (E/M) codes to describe inpatient and outpatient visits in 1992. When originally published, the E/M code descriptors were ambiguous and unclear, resulting in the reporting of erroneous levels of service and the inability to audit or oversee the delivery of services to Medicare beneficiaries.

In 1995, the Centers for Medicare & Medicaid Services (CMS) revised the E/M guidelines to include more specific details about the patient history and the extent of the physical examination. That same year, the AMA and the Health Care Financing Administration (now CMS) introduced their collaboration on the development of E/M documentation guidelines. The AMA emphasized that guidelines were created for the following reasons:

  • to be consistent with the clinical descriptors and definitions contained within the Evaluation and Management Services section in the Current Procedural Terminology (CPT)
  • to be widely accepted by clinicians
  • to be interpreted and applied uniformly by users across the country
  • to minimize any changes in recordkeeping practices

Although the first goal may have been met, achievement of the other three goals would be hotly contested by most orthopaedic surgeons. Most specialists believed the guidelines were punitive due to the lack of a relevant physical exam.

Two years later, the E/M documentation guidelines were revised to include single-specialty physical examinations. However, physicians and national specialty societies objected to the burden of these guidelines and asked that they be reworked. An extensive revision effort by the AMA and specialty societies was rejected by CMS in 2000. At that time, CMS revealed its new "draft" E/M documentation guidelines, using examples of actual physician documentation of examination and medical decision making.

In 2001, the Department of Health and Human Services stopped all work on E/M documentation guidelines to reassess the effort, because consensus with providers was nowhere in sight. As a result, the 1995 and 1997 documentation rules currently remain in effect. The only difference between the two sets of rules is the inclusion of the single-specialty physical examination in the 1997 documentation guidelines.

Medical decision making
The 1995 documentation guidelines for the patient history and medical decision making can be found on the CMS website. Both the official CMS documentation guidelines and the CPT book state that medical decision making takes into consideration the following three factors:

  • The number of possible diagnoses and/or the number of management options that must be considered
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed
  • The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options

Both the CPT book and the CMS documentation guidelines include Table 1, which shows the relationship among these three factors.

The documentation guidelines were integral to the development of "score sheets" that are used by Medicare Administrative Contractors and by physicians, coders, electronic medical record systems, and private payers to evaluate the complexity of medical decision making. Before being released, the 1995 E/M documentation guidelines were beta-tested at Marshfield Clinic in Wisconsin. As part of the testing process, the clinic's staff helped their regional Medicare carrier develop an audit worksheet that included a scoring system for medical decision making. Although these score sheets have never been included in the "official" CMS or CPT documentation guidelines, they are commonly used to evaluate medical decision making.

Tables 2 through 5 represent a facsimile of the medical decision-making scoring sheets, which may vary slightly in language by payer. The system quantifies some of the elements of medical decision making defined in CPT with points scoring. Table 2 shows the final results for determining the level of decision making.

Activities that result in data review and diagnosis/management options points are outlined in Tables 3 and 4. Table 5 outlines activities that determine the level of medical decision-making risk, but it does not rely on a points system for risk assignment.

To determine the level of medical decision making, providers must first complete Tables 3 and 4, then transfer the result to Table 2. For example, in Table 3, for each category of reviewed data identified, the provider would first circle the number in the points column, then total the points and insert the total in Table 2.

The provider would then complete Table 4 by identifying each problem or treatment option mentioned in the record. The number of each problem or treatment option mentioned would then be entered in each of the categories in Column B of Table 4. Note that two categories have a maximum number. The number of problems or treatment options would then be multiplied by the points shown in Column C and the result listed in both Column D and Table 2.

Finally, the risk table (Table 5) would be used as a guide to assign risk factors. It should be understood that the table does not contain all specific instances of medical care. The provider would circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled. That level of risk would then be transferred to Table 2.

Risk determination
Although the tables quantified with points are not included in Medicare's official guidelines, the narrative risk table (Table 5) is included in the original and current CMS documentation guidelines, with the following instructions:

  • Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.
  • If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure, eg, laparoscopy, should be documented.
  • If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.
  • The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.

Table 5 may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.

The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk by selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem[s], diagnostic procedure[s], or management options) determines the overall risk.

To make the risk table more specialty specific and relevant, the AAOS initially published a modified risk table in the AAOS Bulletin (July 1997: HCFA, AMA tell how to code for E/M), AAOS Now (May 2007: Updating guidelines and tables for office E/M coding), and in The Orthopaedic CPT Coding Guide.

Over the years, as the documentation guidelines have been more broadly applied and carriers published additional guidance, the AAOS observed that carrier guidance was based on the CMS risk table. It is currently the recommendation of the AAOS that the standard CMS risk table included in this article be used when evaluating the risk component of medical decision making.

Although scoring tools were initially developed for use by Medicare carriers to audit services submitted by providers, they are used by many payers to determine whether the level of service reported is reflected by the documentation in the medical record.

The introduction of the electronic health record (EHR) makes it easy to duplicate notes or reuse information obtained in a previous encounter. Payers have made it clear that medical necessity is the overarching criterion, and additional information in the record that is not required to make a diagnosis or treat a problem should not be considered when choosing the level of E/M service (AAOS Now, September 2014: Medical Necessity ≠ Medical Decision Making).

Practices should review the use of documentation from previous encounters to ensure that only elements that are relevant to the current visit are used for assigning the level of E/M service.

Additionally, groups that perform internal compliance audits may consider using the score sheets as tools to determine reporting accuracy.

Margaret M. Maley, BSN, MS, is a senior consultant specializing in orthopaedic coding and reimbursement with KarenZupko & Associates.

M. Bradford Henley, MD, MBA, is treasurer on the AAOS Board of Directors, chair of the AAOS Finance Committee, and liaison to the AAOS Coding, Coverage, and Reimbursement Committee.


  1. CPT Assistant, Winter 1994
  2. CPT Assistant, Spring 1995
  3. CPT Assistant, Summer 1995
  4. 1995 Documentation Guidelines for Evaluation and Management Services
  5. 1997 Documentation Guidelines for Evaluation and Management Services
  6. 1995 documentation guidelines for the patient history and medical decision making: