Part B Insider (Multispecialty) Coding Alert

History:

Don't Use HPI Info to Satisfy ROS

In a recent set of "frequently asked questions," Part B carrier National Heritage Insurance Co. said that providers shouldn't use items from the HPI to satisfy the separate review of systems (ROS) portion of the history. "If the HPI addresses more than the four required, and the additional HPI addresses a system, credit may be given for review of one system," NHIC said.
 
But it's probably easier just to make sure you put information that addresses systems into the ROS portion. Any information the patient provides about symptoms such as a fever should go into the ROS.
 
"If you continue to ask people questions, you're going to get enough,"  Talbert says.
 
For the past family and social history (PFSH) portion of the history, "you don't have to ask them every time they walk in to tell you about their mother," Talbert says. For a recurring patient, you can ask about her current prescriptions and allergies. For a new patient, though, you need a full history.