CMS has made clear that the billing provider, and not a medical assistant, must personally document the patient’s history of the present illness (“HPI”). The HPI includes the quality, severity, duration, timing, context, and associated signs and symptoms of the patient’s current health complaints. The HPI does not include the patient’s past, family, and social history. A medical assistant may document the patient’s past, family, and social history as long as the billing provider subsequently reviews such information.
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