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

The Medicare Learning Network

The Medicare Learning Network® (MLN) Educational Web Guides Documentation Guidelines for Evaluation and Management (E/M) Services page offers health care professionals E/M services information and resources. You can access three E/M publications below:

E/M services health care professionals may use either version of the 1995 or 1997 documentation guidelines, not a combination of the two, for a patient encounter. An FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services provides information on using the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 documentation guidelines to document an E/M service performed on or after September 10, 2013.  

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