Documentation Guidelines

July 19th, 2016

What is the difference between the two sets of Guidelines?

There are two major differences.  The first is in the history of the present illness (HPI).  In the 1995 Guidelines, in order to document a history of the present illness at a detailed level, the clinician must document four elements of the history of the present illness.  These elements are: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.  In the 1997 Guidelines, in place of documenting four elements, the clinician could document the status of three chronic diseases.  Documenting the status of three chronic diseases is more than just listing them; it is describing the status of each in the history section of the note.  

The second difference between the 1995 and the 1997 Guidelines is in the exam.  The 1995 Guidelines did not have a well-defined exam in for an expanded problem focused exam and a detailed exam. The expanded problem focused exam was defined as “a limited exam of 2-7 body part/organ systems” and a detailed exam as an “extended exam of 2-7 body parts/organ systems.”  Some carriers and auditors defined expanded problem focused as 2-4 body parts/organ systems and a detailed exam as 5-7 body parts/organ systems.  This was never formally endorsed by CMS and is open to challenge.  The 1995 Guidelines did not have any definition for what a complete single organ exam would be, and so auditors had to use their judgment.  In the 1997 Guidelines, the exam components were very specific and single specialty exams were included.  These are the two major differences between the 1995 and the 1997 Guidelines.

1995 Documentation Guidelines (pdf)

1997 Documentation Guidelines (pdf)


Documentation Guidelines. (2016, July 19). Find-A-Code Articles. Retrieved from

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