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01051184

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When determining an established office visit, if you have HPI and PFSH documentation, do you also need ROS?
 

dmaec

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no, you don't "need" one, but -if you don't have an ROS - it's brings the HISTORY component down to a Problem Focused HISTORY - because the History Component is equal to the lowest category documented. SO - even if you have a COMPREHENSIVE HPI and PFSH - but no ROS - you still only have a PROBLEM FOCUSED "HISTORY".
 
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