Which E/M Documentation Guidelines were used for office visits prior to January 1, 2021?

The correct choice refers to the 1995 and 1997 Documentation Guidelines for Evaluation and Management (E/M) services, which governed how office visits were documented prior to the updates that took effect on January 1, 2021.

The 1995 guidelines provided the foundational framework for documenting E/M services, outlining specific requirements for components such as history, examination, and medical decision-making for various levels of service. In 1997, additional guidelines were introduced that refined the documentation requirements and added detail, particularly in terms of the examination component and the medical necessity of the visit.

These two sets of guidelines were actively used until the implementation of new guidelines in 2021, which shifted the focus away from the complexity of documenting the history and examination components and moved towards a more simplified approach based on medical decision-making and time spent. Therefore, understanding that the 1995 and 1997 frameworks shaped the practices and standards for office visit documentation is critical for appreciating the evolution of E/M documentation requirements in the healthcare field.