Forum - Questions & Answers

Jul 15th, 2015 - shell24

Hpi/ros

I've noticed one of my MD's using this as the HPI:

"Patient returns for routine screening for breast cancer and breast cancer recurrence. No current medical complaints or change in medical history or family history.
Breast cancer surveillanceā€

From that I only get Location for the HPI. She keeps coding as 99213's. The PE is Detailed & the MDM is SF

Would anyone use "no current medical complaints" as a Complete ROS?

I most definitely would NOT, however she passed her last audit from our Compliance department & I can't figure out how when all of the notes have that statement in the HPI, no ROS, 3/3 PFSH, PE is Detailed & the MDM is SF (stable, no add'l w/u, follow up next year).




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