e/m coding

Can anyone tell me how you would code this: This is what is noted in the HPI:
Patient continues to complain of scratchy throat, cough and tickle. This has been present for several months.
I got four elements to score an Ext, but I was told that since he has one additional symptom, in this case the tickle, that this can be counted in the ROS under ENT. My question is, can you do this or would you not count ENT since you already used it to score in the HPI?

Ros

The ROS is a series of questions that helps identify signs and/or symptoms that the patient may be experiencing or has experienced.

What is the ROS?
• A screening device to uncover potentially significant symptoms not otherwise elicited.
o Symptoms related to the HPI
o Other Active Problems
o Determine the pertinent positives and negatives which will aid in making a diagnosis.

Since the patient presented with these symptoms (scratchy, cough, tickle) as part of the reason for the visit (chief complaint), then this is not part of the ROS. If the patient said, "I have a cough" and the physician further inquired by asking the patient if he was having any discharge, pain in the throat or ears, pain when swallowing, etc. Then this would be part of a ROS.

You can't count a ROS that is part of the chief complaint, other then counting it as problem pertinent ROS.

e/m

Can you tell me where I can find an officical guideline on this to show our auditor? I believe that she is giving us the wrong advice.

double dipping between HPI and ROS

CMS never addressed this specifically. There is an old letter saying that they don't mean the doctor has to "redocument" to get credit for both, but it doesn't specifically answer this question.

There are many auditor/consultant opinions about this, but I don't know of any CMS documentation.

Personally, if I've used up all of the HPI items, and then the MD goes on to discuss the system, I'll count is as ROS. But there have to be enough words and detail. Using GI as an example:

Patient present with three day history of loose stools, explosive, not responsive to pepto bismol. Let's say we have four HPI elements.

If the MD goes on to say: no pain, no N/V, no bloating, no gas, then I'll credit GI in the ROS.

But, this is my opinion: I don't have a definitive source to support it.