Soundings Views and reviews

Evaluation and management guidelines

BMJ 1998; 317 doi: (Published 19 September 1998) Cite this as: BMJ 1998;317:822
  1. George Dunea, attending physician (
  1. Cook County Hospital, Chicago, USA

    Last year the Health Care Financing Administration issued new rules indicating how doctors must document the services for which they are billing Medicare. The guidelines define four levels of service: problem focused; expanded problem focused; detailed; and comprehensive. For each level there are detailed instructions on how to document the chief complaint, present illness, review of systems, and past, family, or social history. Each history of the present illness is defined as a chronological description which may include one or more of the following elements: location, quality, severity, timing, context, modifying factors, and associated symptoms and signs. The lowest level requires three …

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