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Element(s) of CC to ROS

2

20Hiker16

Guest
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34
Location
Raymond, ME
QUESTION:

CC: Chest Pain

1) No or very little HPI documented. Can "chest" be abstracted from CC and used as location?

CC: Chest Pain with SOB

2) No or very little ROS is documented. Can "SOB" be abstracted from the CC and used in the ROS as Respiratory?

Thank you.
 
Thank you, Nandhakumar.

We have had consultants come in to our facility and say we can use information from the ROS, if appropriate in the HPI, and can pull HPI from the chief complaint.

Supervisor reviewed Medicare E/M Guidelines and said she did not see any contradiction in the 1995 guidelines saying we could not.

But, we learned from the beginning that although the CC is part of the HPI, it remains a separate statement and information within the CC should not be "borowed" for other elements that are missing in the HPI or ROS. We can only borrow or use elements from HPI to ROS and ROS to HPI if necessary.

Being that said, do you have any solid references for me to back up our thoughts?
 
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