What guidelines was the Marshfield Clinic E/M worksheet designed from?

The Marshfield Clinic E/M worksheet was designed based on the 1995 Documentation Guidelines (DGs). These guidelines outline how healthcare providers should document evaluation and management (E/M) services to ensure that the level of service appropriately represents the complexity of patient encounters.

The 1995 guidelines provide a detailed framework for determining the complexity of office visits and include stipulations on components such as history, examination, and medical decision-making. Understanding these guidelines is crucial for coders and providers to ensure compliance with coding standards and to maximize reimbursement accuracy.

While there have been revisions and updates to the documentation guidelines following the 1995 version, specifically in 1997 and again in 2021, the Marshfield Clinic's use of the 1995 guidelines indicates a focus on the foundational documentation practices established during that period. This allows the clinic to apply standardized criteria that many providers are familiar with, ensuring clarity and consistency in their coding processes.