Documenting in both HPI AND ROS


Carlisle, PA
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I'm taking the CPMA exam in May and in the course it states that sometimes credit given in both the HPI location and to the review of a system. For example: "The patient states that she has a sore throat". (this alone is only HPI). But if it reads "The patient states that she has a sore throat. She denies any postnasal drip or fullness in her ears when she swallows". They are saying it goes in the HPI AND the review of the ENT system. This is what throws me at times. Is there alot of this on the exam? How do you get better at recognizing this type of documentation and when to apply it in both?


Knoxville, TN
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I have not taken the CPMA exam but just make sure you do not use anything in you HPI for both the HPI and can't double dip. Yes you will need to take your ROS from your HPI if needed. In this case you would have the ENT for the ROS for "denies any postnasal drip or fullness in her ears when she swallows" have a complete HPI/ PFSH and the ROS that has 9 elements (new patient). If the entire chart justifies a level 99205 but you have have 9 elements in your ROS you would pull the ENT from your HPI to have a detailed ROS that would then give you a 99205. If that would not have been caught and pulled from the HPI you would have billed a 99204.

My suggestion is to see if you can't locate E&M scenarios.

Hope this helps!
Renae CCS, CPC


Gouverneur, NY
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Most providers will list there ROS info in there HPI. It is usually easy to determine by negative / positive documentation. Then under review most will say: all other systems negative except for whats in HPI. Now the problem with this is making sure there really is ROS in the HPI. They can't use a statement about other systems if they did not review anything in HPI. For instance:
member is here with sore throat X 4 days. There is no ROS in this statement.
As a coder and auditor, I began by using the cross out method. Print a note and begin to cross off documentation for each section: For instance
member here with sore throat x 4 days. No fever, denies fatigue, hurts when swallowing, denies difficulty breathing.
I would look at my audit tool and determine what I have: I use E/M Audit Tool you can print this for free.
Under HPI I have location and duration
Under ROS I have: constitutional no fever, Respiratory no difficulty breathing, ENT: hurts when swallowing
Heres is something else to watch for: if provider uses that statement of all systems negative except for HPI then see if they listed all 14 systems as reviewed.. For instance if a provider says all systems then the question should be did you really do GYN / PSYCH / and if so what is the reason for this review. If they are only here for minor problem then documentation must support reason for visit as well.

Any other questions. please reach out. If I'm not sure I can help I will try to find an answer...hopefully :)

Sandi B. CPC, CPMA