Professional services provided on or after Sept. 10, 2013, will be allowed by CMS to use the 1997 Documentation Guidelines (DG) concerning the extended History of Present Illness (HPI) in conjunction with the 1995 guideline for extended HPI.
Currently, the 1997 DG states: “The medical record should describe at least four elements of the present illness (HPI), or the status of at least three chronic or inactive conditions”, allowing, as an alternative, the status of at least three chronic or inactive conditions to be used to meet the definition of extended HPI.
It is important to note that these guidelines do not say the practitioner may “list”. In order to meet the standard of this guideline, the practitioner must describe the status of each chronic or inactive condition.
FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services
Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?
A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.
The original document can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/EM-FAQ-1995-1997.pdf