Effective Sept. 10, the Centers for Medicare & Medicaid Services (CMS) has revised its Evaluation and Management (E/M) Documentation Guidelines (DG), to allow physicians to use the 1997 DG for an extended history of present illness (HPI) with the other elements of the 1995 DG to document an E/M service. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for either set of DGs.
The revised guideline is presented as a Question and Answer on the CMS website:
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.