Exam documentation: charting within the guidelines.

T 1997 version of Medicare’s “Documentation Guidelines for Evaluation and Management Services” defines complete exams for 11 organ systems and significantly expands the definitions for multisystem exams. When the guidelines were released, some physicians appreciated their specificity, while many declared them too burdensome to use. Developed as a replacement for the 1995 documentation guidelines, the 1997 version produced such an uproar among physicians and organized medicine that the Centers for Medicare & Medicaid Services (CMS) first delayed its implementation and then ultimately declared it an alternative to, rather than a replacement for, the 1995 version (see “What about the 1995 guidelines?” page 25). The purpose of this article is to review the guidelines and help you determine whether your documentation would stand up to an auditor’s evaluation. We’ll focus on the 1997 guidelines and the multisystem exam, since they are commonly used in family medicine. An overview of the single-system exam requirements is available with the online version of this article (http://www.aafp. org/fpm/2010/0500/p24.html). If you’d like to brush up on the rest of the guidelines, see the article on history documentation in our March/April 2010 issue (http://www. aafp.org/fpm/2010/0300/p22.html), and don’t miss the next article in this series, which will focus on documenting medical decision making.