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The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.

This article does not apply to services performed after 1-1-2023.

Question:

What does it mean when it says a code requires an “interval” history? This question related to the 1995/1997 Documentation Guidelines.

Answer:

It is a history that does not require past medical, family, or social history.

An interval history is needed for a subsequent hospital visit or subsequent nursing facility visit. CPT^® wording is, “an interval expanded focused history” or “an interval detailed history,” depending on the level of visit.