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
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