![]() The 1995 CMS guidelines were issued as a joint effort between the AMA and HCFA (now CMS) to help physicians understand the CMS guidelines in context with the AMA's Current Procedural Terminology (CPT) coding system. The complete 1995 Documentation Guidelines are available on the CMS website. Consequently, this FAQ will focus on the 1995 DG for CMS discussions. The vast majority of Emergency Medicine physician groups use CMS' 1995 DG over the 1997 DG. For E/M codes, CMS instructs their contractors to audit physician documentation by either CMS' 1995 Documentation Guidelines (DG) or their 1997 DG, whichever most benefits the physician. CMS is obligated to formally notify providers of its modifications to CPT requirements in the absence of such specific notifications CPT requirements are understood to be in effect for Medicare patients. CPT Evaluation and Management (E/M) guidelines are generally less quantitative, providing the clinician some qualitative latitude based on the medical necessity of a particular clinical encounter.
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