# HPI and 1995 guidelines



## Love Coding! (Feb 2, 2009)

Would this be accurate to say that under 95 guidelines if there is no chief complaint that you can use 3 chronic or inactive conditions?  Or does this apply only to 97 guidelines?  I thumbed through the CPT book couldn't find an answer and emuniversity.com states you can only use 3 chronic or inactive conditions under 97 guidelines...

Please help!

Thanks,

dscoder74


----------



## FTessaBartels (Feb 2, 2009)

*HPI vs Chief Complaint*

The chief complaint must be stated on all documentation.  

The HPI can be either the elements (location, quality, severity, timing, duration, context, modifying rfactors, associated signs/symptoms)  OR the status of 3 chronic conditions. 

This "3 chronic conditions" was added with the 1997 guidelines, but was never stated that it could apply to the 1995 guidelines.  Nevertheless, *some *carriers will allow you to "mix" the 1997 and 1995 guidelines by accepting the 3 chronic conditions for HPI while still using the 1995 guidelines for the exam. 

Check with your carrier. And be sure to include the protocol in your practice's compliance plan. 

F Tessa Bartels, CPC, CEMC


----------



## RebeccaWoodward* (Feb 3, 2009)

An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.

!DG: 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

Page 9 on the '97 guidelines

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf


----------



## 1073358 (Feb 9, 2009)

dscoder74 said:


> Would this be accurate to say that under 95 guidelines if there is no chief complaint that you can use 3 chronic or inactive conditions?  Or does this apply only to 97 guidelines?  I thumbed through the CPT book couldn't find an answer and emuniversity.com states you can only use 3 chronic or inactive conditions under 97 guidelines...
> 
> Please help!
> 
> ...




It is highly recommended that they state a CC, but not required. As long as it can be clearly inferred from the note, that is acceptable.


----------



## Love Coding! (Feb 10, 2009)

*Thank you!*

Thanks to all of you, I have been up to my ears with dictation.  Sorry for the late response, until next time....

Have a great day!

dscoder74


----------

