Forum - Questions & Answers
Hpi / ros
Is the HPI interchangeable with the ROS?
If the patient presents (only documented as) for nausea and vomiting: I can count 1 for HPI and 1 for ROS.
If the patient presents (only documented as) for nausea: Can I count the nausea in the HPI and then count it again in the ROS under GI symptoms?
Thank you!
Hpi/ros
There is an E/M question and answer resource on the WPS Medicare web site. I am in Iowa. This question is asked.
The reply from WPS is:
A clearly documented medical record would prevent the need to double-dip for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statment in both areas if necessary.
Check your Medicare Carriers web site for E&M information.
I also have found a letter From HCFA to Lynx Medical Systems Inc., asking the same question. Dr. McCann, Executive Medical Officer at HCFA said:"it is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirement for the ROS. It is important that the information which is provided can be inferred accurately and appropriately by a reviewer to determine level of service and medical necessity. The Documentation Guidelines are meant to help identify which elements constitute and E/M service and not to be perceived as a burden to the Physician."
This letter is on the Amercan College of Emergency Physicians site.
Louise
but....
if the HPI requires 2 items and ROS one item, you cannot count nausea and vomiting as 2 HPI and count nausea as one ROS.
Hpi / ros
There are four articles in the data base about HPI and ROS.
Their titles are:
Review of systems
History of the present illness
Do headings matter in an E/M note
and
Who can document the HPI.
This article, by Todd Thomas, has been read over 1000 times. (Nancy's article, An Eye on Coding, has been read over 100 times, as well.)
Search for these titles or any topic, in the search field above, "Look it up!"